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TRANSVESICAL    PROSTATECTOMY 

IN 

TWO  STAGES 


Paul  Monroe  Pilcher 


4  PAUL  MONROE  PILCHER. 

ring  wide  open.  That  this  frequently  occurs  is  well  shown  by 
many  specimens.  However,  it  is  hard  to  accept  the  theory 
that  in  some  cases,  or  in  many  cases,  the  enlargement  of  the 
median  lobe  takes  place  in  the  direction  of  the  lateral  lobes, 
displacing  them  and  causing  atrophy  of  these  lobes,  compressing 
them  out  into  a  shell-like  capsule ;  to  produce  a  lateral  extension 
of  an  adenoma  of  the  median  lobe,  the  expansion  must  take 
place,  not  along  the  avenue  of  least  resistance,  but  against  a 
firm,  well-developed  structure.  Judging  from  the  anatomical 
relations  as  found  on  the  operating  table,  Tandler's  conclusions 
as  to  the  part  of  the  prostate  involved  in  the  obstruction  are 
incorrect. 

Fig.  I  is  an  illustration  taken  from  the  work  of  Tandler 
and  Zuckerkandl,  showing  a  sagittal  section  through  the  pelvis 
in  a  case  of  prostatic  hypertrophy.  We  agree  that  this  repre- 
sents a  typical  case  of  median  lobe  enlargement.'  A  number 
of  other  illustrations  which  are  shown  in  the  work  of  Tandler 
and  Zuckerkandl  are  unquestionably  examples  of  median  lobe 
enlargement,  for  in  each  the  adenomatous  mass  is  more  or  less 
symmetrical  in  the  median  line  and  is  forced  through  the  sphinc- 
ter dilating  it.  The  same  phenomenon  has  been  plainly  shown 
in  many  of  our  own  specimens,  for  example,  Figs.  2,  3,  and  4, 
At  the  same  time,  the  enlargement  of  the  lateral  lobes  without 
the  median  lobe  enlargement  may  take  place,  and  in  such  cases 
the  sphincter  is  greatly  dilated  and  surrounds  the  hypertrophied 
mass.  Such  a  case  is  seen  in  Fig.  5.  In  this  case  the  lateral 
lobes  have  become  enormously  hypertrophied  and  have  carried 
the  median  lobe,  which  is  also  enlarged,  through  the  sphincter 
well  into  the  bladder.  It  cannot  be  conceived  that,  after  the 
enucleation  which  was  accomplished  in  this  case,  any  prostatic 
tissue  was  left  behind  unless  it  was  the  posterior  lobe  which  is 
so  nearly  independent.  Fig.  6,  however,  shows  a  different 
condition.  This  was  a  case  of  complete  urinary  obstruction, 
which  had  lasted  for  three  years.  B' ,  B'  are  the  adenomatous 
lateral  lobes.  5  is  a  greatly  hypertrophied  m^edian  lobe.  A  is 
a  crescent-shaped  calculus,  and  the  remaining  pieces  of  tissue 
are  compressed  and  atrophied  bits  of  prostatic  tissue  which  still 


TRANSVESICAL  PROSTATECTOMY. 


remained  imbedded  in  the  capsule  of  the  prostate  after  the 
adenoma  had  been  enucleated.  Fig.  7  is  an  example  of  sym- 
metrical enlargement  of  the  median  and  both  lateral  lobes. 
Fig.  8  is  an  example  of  bilateral  hypertrophy  without  any 
median  lobe  enlargement.  The  specimen  is  very  distinct  and 
convincing  on  this  point.  Fig.  9  is  another  example  of  irregu- 
lar hypertrophy  of  the  lateral  lobe  with  very  little  median  lobe 
enlargement.  Fig.  10  shows  a  specimen  removed  in  one  piece 
in  which  the  median  lobe  is  enlarged  and  has  pushed  forward 
into  the  bladder  and  distorts  the  urethra,  lifting  it  up  and  mak- 

FlG.   4. 


Median    Lobe 


r^ 


Eight  Lobe 


Drawing  showing  tlie  three  lobes  of  the  prostate  separated.    Same  specimen  as  Fig.  3. 

ing  it  almost  impossible  to  empty  the  bladder.  The  position  of 
the  sphincter  is  indicated  by  the  arrows.  Fig.  ii  shows  still 
another  type  of  development.  The  lateral  lobes  in  this  case 
had  been  previously  removed  by  perineal  operation.  The  symp- 
toms persisted  and  three  years  later  this  median  lobe  enlarge- 
ment, with  a  very  freely  movable  ball  valve  attachment,  was 
taken  out  by  a  transvesical  operation.  No  remnants  of  the 
lateral  lobes  could  be  found.  It  is  interesting  to  note  the 
position  o_f  the  internal  sphincter  as  indicated  by  the  arrows. 


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TRANSVESICAL 

PROSTATECTOMY  IN 

TWO   STAGES 

WITH  REMARKS  UPON  THE  PATH- 
OLOGY AND    CLINICAL    PHASES 
OF  PROSTATIC  OBSTRUCTION 


BY 

PAUL  MONROE  PILCHER,   A.M.,  M.D. 
PILCHER  PRIVATE  HOSPITAL 

OF  BROOKLYN— NEW   YORK 


J.  B.   LIPPINCOTT  COMPANY 

PHILADELPHIA  e'  LONDON 
1914 


Reprinted  From 

ANNALS  OF  SURGERY 

April   1914 


TRANSVESICAL  PROSTATECTOMY  IN  TWO 
STAGES. 

BY  PAUL  MONROE  PILCHER,  M.D., 

OF  BROOKLYN,  NEW  YORK. 

I.  THE  PATHOLOGY  OF  CHRONIC  PROSTATIC  OBSTRUCTION.  II.  CONDITION  IN- 
FLUENCING THE  CHOICE  OF  TREATMENT-METHODS.  III.  THE  THREE  PHASES 
OF  INTERRELATION  BETWEEN  OBSTRUCTION  AT  THE  VESICAL  OUTLET  AND 
RENAL  FUNCTION.  TV.  THE  INDICATIONS  FOR  AND  THE  TECHNIC  OF 
SUPRAPUBIC  CYSTOSTOMY.      V.   TECHNIC  OF  TRANSVESICAL  PROSTATECTOMY. 

INTRODUCTION. 

Since  we  have  adopted  the  transvesical  operation  for  the 
reHef  of  urinary  obstruction  due  to  changes  in  the  prostate, 
we  have  been  able  more  fully  to  study  the  so-called  living  pa- 
thology of  the  condition  inasmuch  as  the  vesical  outlet  can  be 
studied  with  the  prostate  in  situ,  the  nature  of  the  obstructing 
mass  determined  and  the  resultant  deformities  of  the  bladder 
studied.  The  removal  of  prostates  in  one  piece  in  many  cases 
and  the  interurethral  enucleation  in  others  has  provided  us  with 
new  material  for  extending  our  observations  concerning  the 
gross  pathology  of  the  disease. 

Studying  this  last  series  of  cases  we  are  led  to  disagree  with 
some  of  the  more  recently  advanced  theories  concerning  the 
pathology  of  the  disease.  In  presenting  this  subject,  therefore, 
we  first  offer  our  observations  on  the  points  in  question.  We  do 
not  reiterate  much  of  the  work  which  has  already  been  pub- 
lished by  Dr.  Lewis  S.  Pilcher  and  myself.^ 

^  Pilcher,  Lewis  S. :  Choice  of  Operative  Method  for  Removal  of  the 
Hypertrophied  Prostate.    Annals  of  Surgery,  1905,  xli,  565. 

Observations  Upon  the  Removal  of  the  Prostate  for  the  Cure  of  Pros- 
tatic Dysuria.    New  York  State  Journal  of  Medicine,  June,  1906. 

Urinary  Obstruction  from  Prostatic  Hypertrophy.  Year  Book  of  the 
Pilcher  Hospital,  191 1,  i,  p.  60. 

Pilcher,  Paul  M. :  Pathology  and  Etiology  of  Obstructive  Hypertrophy 
and  Atrophy  of  the  Prostate  Gland.    Annals  of  Surgery,  1905,  xli,  481. 

Choice  of  Operation  for  the  Relief  of  Prostatic  Dysuria  and  the  Pre- 


2  PAUL  iMONROE  PILCHER. 

I.    THE  GROSS  PATHOLOGY  OF  PROSTATIC  HYPERTROPHY. 

Most  of  the  recent  articles  dealing  with  prostatic  hyper- 
trophy have  presented  evidence  and  theories  concerning  the 
gross  pathology  of  the  prostate.  The  work  of  Tandler  and 
Zuckerkandl  ( i )  tended  to  show  that  all  of  our  previous  ideas 
of  the  gross  pathology  of  prostatic  hypertrophy  were  wrong. 
Lowsley  (2)  presented  his  study  of  a  series  of  sections  of  the 
human  prostate  in  its  early  developmental  period,  which  were 
distinctly  in  contrast  to  the  series  presented  by  the  Austrian 
scientists.  Wilson  and  McGrath  (3)  presented  their  studies  of 
over  400  specimens  and  agreed  to  a  certain  extent  with  the 
theories  of  Tandler  and  Zuckerkandl.  Henry  Wade  (4)  gives 
the  results  of  his  exhaustive  study  of  prostatism  and  deals 
with  the  surgical  anatomy  and  pathology  of  the  operative 
treatment. 

Our  own  observations  have  not  satisfied  us  that  these 
theories  are  absolutely  demonstrated  to  the  satisfaction  of  sur- 
gical pathologists.  Lowsley  agrees  with  the  more  advanced 
pathologists  and  recognizes  five  lobes  in  the  prostatic  mass. 
The  middle  lobe  is  quite  independent  of  the  others  and  its 
tubules  are  distinctly  separated  from  the  others.  They  are 
situated  within  the  gland  structure  and  are  in  relation  with  the 
floor  of  the  urethra.  The  posterior  lobe  is  situated  furthest 
from  the  bladder  and  is  almost  an  independent  structure.  It  is 
further  of  interest  to  note  that  the  tubules  of  the  middle  lobe 
lie  side  by  side  with  those  of  the  lateral  lobes,  but  at  no  point 
do  they  intermingle.  The  lateral  lobes  are  made  up  of  a  series 
of  tubules  on  each  side  of  the  urethra  and  the  acini  of  these 
lobes  form  the  main  mass  of  the  gland.  It  is  distinctly  indi- 
cated that  the  lateral  lobes  are  in  direct  relation  with  the  urethra. 
The  posterior  lobe  seems  to  be  almost  an  independent  structure 
and  is  seldom  involved  in  hypertrophy  of  the  gland.     It,  how- 

liminary  Treatment  Indicated.  Journal  of  the  Michigan  State  Medical 
Society,  January,   1912. 

The  Suprapubic  Two-step  Operation  for  the  Removal  of  the  Hyper- 
trophied  Prostate.     American  Journal  of  Surgery,  June,  igi2. 

The  Operative  Relief  of  Obstructive  Hypertrophy  of  the  Prostate. 
Journal  of  the  Michigan  State  Medical  Society,  September,  1913. 


„.,-.t^r'- 


L.a. 


B.u. 

Sagitta  section  through  the  pelvis,  showing  the  prostate  hypertrophied.  B.u.,  bulbus 
urethralis;  C.g.,  caput  gallinaginis ;  L.a.,  lobus  anterior;  L.m.,  lobus  medius;  R.r.,  recessus 
retrouretericus;  V .s.,  vesicula  seminalis.  A  short  probe  projects  from  the  ejaculatory  duct. 
(Tandler  and  Zuckerkandl,  verlag  von  Dr.  Werner  Klinkhardt,  Leipzig.  Wilson  and 
McGrath.) 


Fig.  2. 


Prostatic  mass  removed  by  transvesical  operation,  rubber  tube  showing  direction  of 
urethra.  Beneath  the  rubber  tube  is  a  greatly  hypertrophied  middle  lobe.  The  lateral 
lobes  are  seen  forming  the  sides  and  roof  of  the  urethra,  but  are  not  in  any  way  obstructive 


Fig.  3. 


Anteviov    Surface 


night 

Lohe 


Median 
Lobe 


Left  Lobe 


Paul  Pi h her. 


Enormous  median  lobe  enlargement  of  the  prostate  with  adenomatous  changes  in  the 
lateral  lobes.  These  lobes  are  smaller  than  normal  and  show  no  atrophy  due  to  pressure. 
The  specimen  presents  a  view  of  the  anterior  face.  The  part  above  the  rubber  tube  was 
entirely  intravesical.     The  anterior  face  is  covered  by  mucous  membrane. 


TRANSVESICAL  PROSTATECTOMY.  -, 

ever,  seems  to  be  a  starting  point  for  malignant  degeneration 
in  many  cases.  The  subvesical  accessory  glands  of  Albarran, 
which  develop  on  the  surface  of  the  median  lobe,  are  not  of 
much  chnical  importance  in  the  experience  of  the  writer. 

As  a  result  of  our  personal  observations  hereinafter  de- 
tailed we  believe ; 

1.  That  Tandier  and  Zuckerkandl  are  mistaken  in  their 
conclusions  that  prostatic  hypertrophy  is  always  a  hypertrophy 
of  the  anatomical  middle  lobe. 

2.  That  Tandier  and  Zuckerkandl  are  incorrect  in  assum- 
ing that  the  so-called  prostatectomy  does  not  in  a  great  majority 
of  cases  mean  practically  total  removal  of  the  prostate.  We 
appreciate  that  in  some  cases  of  irregularly  developed  prostatic 
adenomata  some  prostatic  tissue  becomes  atrophied  and  com- 
pressed and  forms  a  shell  around  the  adenomatous  mass  and  is 
not  entirely  removed  at  operation. 

3.  We  question  that  the  surgical  capsule  is  formed  only  by 
compressed  peripheral  parts  of  the  prostate. 

4.  We  agree  that  the  anatomical  relations  of  the  hypertro- 
phied  prostate  to  the  sphincter  vesicas,  the  bladder  itself  and 
the  ductus  deferentes  recommend  the  transvesical  route  as  the 
one  to  be  chosen  in  removing  an  enlarged  prostate. 

The  first  three  of  the  conclusions  advanced  by  the  Austrians 
are  so  at  variance  with  the  accepted  ideas  of  the  pathology 
of  the  prostate  in  cases  of  obstructive  hypertrophy,  that  the 
writer  took  occasion  to  visit  Vienna  and  study  the  specimens 
which  had  been  prepared  by  Professor  Tandier  and  from  which 
these  conclusions  were  drawn.  The  writer  spent  some  time  in 
going  over  the  question  with  Professor  Tandier  so  that  these 
observations  are  not  based  upon  hearsay.  Studying  Tandler's 
specimens  we  accept  his  theory  that  the  posterior  lobe  seldom 
hypertrophies.  In  other  words,  the  enlargement  takes  place 
toward  the  bladder.  However,  in  my  mind  the  exhibits  do  not 
prove  that  the  enlargement  always  involves  the  median  lobe 
alone.  If  enlargement  of  the  median  lobe  takes  place,  it  must 
proceed  along  the  avenue  of  least  resistance,  which  is  through 
the  vesical  outlet,  gradually  dilating  it  and  forcing  the  sphincter 


4  PAUL  MONROE  PILCHER. 

ring  wide  open.  That  this  frequently  occurs  is  well  shown  by 
many  specimens.  However,  it  is  hard  to  accept  the  theory 
that  in  some  cases,  or  in  many  cases,  the  enlargement  of  the 
median  lobe  takes  place  in  the  direction  of  the  lateral  lobes, 
displacing  them  and  causing  atrophy  of  these  lobes,  compressing 
them  out  into  a  shell-like  capsule ;  to  produce  a  lateral  extension 
of  an  adenoma  of  the  median  lobe,  the  expansion  must  take 
place,  not  along  the  avenue  of  least  resistance,  but  against  a 
firm,  well-developed  structure.  Judging  from  the  anatomical 
relations  as  found  on  the  operating  table,  Tandler's  conclusions 
as  to  the  part  of  the  prostate  involved  in  the  obstruction  are 
incorrect. 

Fig.  I  is  an  illustration  taken  from  the  work  of  Tandler 
and  Zuckerkandl,  showing  a  sagittal  section  through  the  pelvis 
in  a  case  of  prostatic  hypertrophy.  We  agree  that  this  repre- 
sents a  typical  case  of  median  lobe  enlargement.  A  number 
of  other  illustrations  which  are  shown  in  the  work  of  Tandler 
and  Zuckerkandl  are  unquestionably  examples  of  median  lobe 
enlargement,  for  in  each  the  adenomatous  mass  is  more  or  less 
symmetrical  in  the  median  line  and  is  forced  through  the  sphinc- 
ter dilating  it.  The  same  phenomenon  has  been  plainly  shown 
in  many  of  our  own  specimens,  for  example,  Figs.  2,  3,  and  4. 
At  the  same  time,  the  enlargement  of  the  lateral  lobes  without 
the  median  lobe  enlargement  may  take  place,  and  in  such  cases 
the  sphincter  is  greatly  dilated  and  surrounds  the  hypertrophied 
mass.  Such  a  case  is  seen  in  Fig.  5.  In  this  case  the  lateral 
lobes  have  become  enormously  hypertrophied  and  have  carried 
the  median  lobe,  which  is  also  enlarged,  through  the  sphincter 
well  into  the  bladder.  It  cannot  be  conceived  that,  after  the 
enucleation  which  was  accomplished  in  this  case,  any  prostatic 
tissue  was  left  behind  unless  it  was  the  posterior  lobe  which  is 
so  nearly  independent.  Fig.  6,  however,  shows  a  different 
condition.  This  was  a  case  of  complete  urinary  obstruction, 
which  had  lasted  for  three  years.  B' ,  B'  are  the  adenomatous 
lateral  lobes.  5  is  a  greatly  h3^pertrophied  median  lobe.  A  is 
a  crescent-shaped  calculus,  and  the  remaining  pieces  of  tissue 
are  compressed  and  atrophied  bits  of  prostatic  tissue  which  still 


TRANSVESICAL  PROSTATECTOMY. 


remained  imbedded  in  the  capsule  of  the  prostate  after  the 
adenoma  had  been  enucleated.  Fig.  7  is  an  example  of  sym- 
metrical enlargement  of  the  median  and  both  lateral  lobes. 
Fig.  8  is  an  example  of  bilateral  hypertrophy  without  any 
median  lobe  enlargement.  The  specimen  is  very  distinct  and 
convincing  on  this  point.  Fig.  9  is  another  example  of  irregu- 
lar hypertrophy  of  the  lateral  lobe  with  very  little  median  lobe 
enlargement.  Fig.  10  shows  a  specimen  removed  in  one  piece 
in  which  the  median  lobe  is  enlarged  and  has  pushed  forward 
into  the  bladder  and  distorts  the  urethra,  lifting  it  up  and  mak- 

FlG.   4. 


I^edian    Lobe 


r- 


Eight  Lobe 


Drawing  showing  the  three  lobes  of  the  prostate  separated.    Same  specimen  as  Fig.  3. 

ing  it  almost  impossible  to  empty  the  bladder.  The  position  of 
the  sphincter  is  indicated  by  the  arrows.  Fig.  ii  shows  still 
another  type  of  development.  The  lateral  lobes  in  this  case 
had  been  previously  removed  by  perineal  operation.  The  symp- 
toms persisted  and  three  years  later  this  median  lobe  enlarge- 
ment, with  a  very  freely  movable  ball  valve  attachment,  was 
taken  out  by  a  transvesical  operation.  No  remnants  of  the 
lateral  lobes  could  be  found.  It  is  interesting  to  note  the 
position  o"f  the  internal  sphincter  as  indicated  by  the  arrows. 


6  PAUL  MONROE  PILCHER. 

Ill  this  case  we  had  the  obstruction  of  the  enlarged  mass  and 
in  addition  a  ball  valve  action. 

Fig.  12  is  the  photograph  of  a  specimen,  actual  size,  re- 
moved in  one  piece.  It  is  a  perfect  example  of  hypertrophy  of 
both  lateral  lobes  of  the  prostate.  Fig.  13  shows  a  section 
through  the  centre  of  this  mass  and  shows  quite  distinctly  the 
three  lobes,  the  two  lateral  lobes  and  the  median  lobe,  and  their 
position  in  relation  to  the  urethra.  The  median  lobe  extends 
up  like  a  wedge  between  the  two  lateral  lobes  and  is  only  moder- 
ately enlarged.  In  this  connection  reference  may  be  made  to 
the  series  of  photographs  of  specimens  which  were  published  in 
1888  by  Francis  S.  Watson,  of  Boston,  in  his  treatise  on  the 
Operative  Treatment  of  Hypertrophy  of  the  Prostate,  Plate  4 
(reproduced  here  as  Fig.  14)  shows  a  very  important  feature; 
the  lateral  lobes  are  moderately  enlarged,  the  median  lobe  is 
distinctly  enlarged  and  is  projecting  into  the  bladder,  forming 
the  cause  of  the  obstruction.  Distal  to  the  median  lobe  enlarge- 
ment is  seen  a  raised-up  portion,  which  is  the  colliculus  or  veru- 
montanum,  at  which  point  the  vasa  deferentia  empty  into  the 
urethra.  If  the  finger  is  introduced  into  the  urethra  by  the 
transvesical  route  in  enucleating  the  prostate,  one  can  easily 
see  from  the  specimen  how  the  colliculus  may  be  preserved. 
Fig.  15  is  an  undeniable  example  of  hypertrophy  of  both  the 
lateral  and  median  lobes  of  the  prostate.  This  specimen,  which 
is  a  dissection  not  only  of  the  prostate  but  of  the  bladder  as 
well,  shows  exactly  the  relation  which  no  drawing  could  so  well 
express.  Fig.  16  shows  another  phase  which  is  a  bilateral 
hypertrophy  of  the  prostate  with  a  slight  median  lobe  develop- 
ment causing  a  distinct  prostatic  bar.  The  tortuous  course  of 
the  urethra,  the  presence  of  the  colliculus  and  its  relative  posi- 
tion are  clearly  shown.  No  one  could  argue  that  in  these  speci- 
mens such  a  hypertrophy  originates  from  the  median  lobe  alone. 
The  floor  of  the  urethra  is  very  clearly  shown  and  is  seen  to  be 
free  from  all  hypertrophied  tissue.  This  portion  of  the  urethra 
must  invariably  be  involved,  at  least  that  portion  between  the 
colliculus  and  the  sphincter,  in  all  median  lobe  enlargements. 
Fig.  17  is  a  perfect  example  of  median  lobe  enlargement  alone. 


Fig.  5. 


B  .^ 


Photograph  of  hypertrophied  prostate  removed  by  suprapubic  route.  Showing  bi- 
lateral and  median  enlargement.  At  vesical  pole,  .4,  the  capsule  and  mucous  membrane 
of  the  bladder  are  shown  stripped  back  from  the  glandular  portion  of  the  gland.  At  B  is 
seen  the  circular  capsule  which  passes  entirely  around  the  gland. 


Fig.  6. 


Photograph   of   prostatic   masses   removed    by   transvesical    route       A     i.   a   cresce^^^ 
shaped  calculus;  B.  a  large  median  lobe;  B'  B'    the  two    f^«^?,l'°^es      The  other  Pieces 
tissue  shown  in  the  specimen  are  atrophied  prostatic  tissue  adherent  .o  the  capsule. 


Fig.  7- 


Specimen   removed   by   transvesical   operation   showing  symmetrical   enlargement  of  both 
median  and  lateral  lobes. 


Fig.   8. 


Specimen  removed  by  transvesical  operation  showing  hypertrophy  of  lateral  lobes  without 
involvement  of  median  lobe. 


Fig.  9. 


Specimen  removed  by  transvesical  operation  showing  irregular  hypertrophy  of   the  lateral 
lobes  with  very  little  median  lobe  enlargement. 


Fi<;.    I. 


Specimen  removed  by  transvesical  operation  showing  marked  median    lobe  enlargement 
with  practically  no  lateral  lobe  enlargement. 


Fig.    II. 


Median  lobe  enlargement  with  ball  valve  attachment. 


Fig.    12 


<:„rfaor'^f^fi!!!"''"'^  °^  ^^^  prostate  in  which  the  two  lateral  lobes  are  involved  The  vesical 
within  it/ol^  prostate  appears  at  the  top  of  the  picture.  This  specimen  was  removed 
w  thm  Its  capsule  and  is  a  perfect  example  of  coincident  hvpertrophy  of  both  lateraUobes 
th^  fnnl''"^  '^'''^^'^  ^^^'""^  ^"^'^  enlargement.  The  section  through  this  mass  fs  seen  in 
^.i^  Iffv,^^"'^  ,Yhich  shows  the  narrow  cleft  occupied  by  the  urithra  The  tvvo  lateral 
masses  and  the  small  adenomatous  median  lobe  are  seen  'J  ureinra.     ine  tv^o  lateral 


Fig.   13. 


Cross  section  of  specimen  shown  in  Fig.  12  showing  relation  of  median  lobe  and  two  lateral 

lobes  to  the  urethra. 


Fig.  14. 


*^-5^ 


•.A 


i'V/ 


Bilateral  and  median  lobe  hypertrophy  of  prostate.  Position  of  coUiculus.  This  photo- 
graph shows  the  exact  relation  of  the  urethra,  hypertrophied  prostate  and  bladder  as  an 
example  of  moderate  bilateral  hypertrophy  of  the  prostate,  with  median  lobe  enlarged  and 
projecting  into  the  bladder,  the  median  lobe  forming  the  chief  obstruction.  Following  the 
urethra  upward  from  the  bladder,  it  will  be  seen  that  the  urethra  inclines  sharply  downward 
due  to  the  bulging  of  the  median  lobe,  which  forms  the  floor  of  the  urethra  as  far  forward  as 
the  colliculus.  If  the  finger  were  introduced  into  the  urethra  through  the  bladder,  it  can  be 
easily  seen  from  this  picture  how  the  entire  prostate  could  be  removed  without  injury  to  the 
colliculus.  (Reproduced  from  Francis  S.  Watson's  work  on  The  Operative  Treatment  of  the 
Hypertrophied  Prostate.) 


Fig.  15- 


Photograph  of  bladder  and  prostate  which  speaks  for  itself^  i^£;,-P?ophy%?bot"hfa"t! 
how  anyone  would  deny  that  this  P^'^^-'='=',PL^TheSoBraDh  showing  the  distinct  rela- 

;kTrSSL??,r  Praii-S':  W^^-^n-^k^T^E  'StlSt.J-P-LlmSJ  o.    .h.  Hyper- 

trophied  Prostate.) 


Fig.  i6. 


'^^^2 


'    ■«--7fi' '  ^'-*T'j»*  ^-1  ■.■at  ■    -'^ 


Photograph  of  another  specimen  of  obstructive  hypertrophy  of  the  prostate  demon- 
strating another  phase  of  hypertrophy  of  the  lateral  lobes.  Position  of  the  colliculus.  In 
this  case  the  two  lateral  lobes  have  developed  unequally,  that  on  the  right  side  of  the  speci- 
men being  much  the  larger  and  distorting  the  urethra  very  greatly.  Both  lateral  lobes  are 
hypertrophied  and  the  median  lobe  is  represented  by  a  thickened  area  which  becomes  a 
bar  because  of  its  being  raised  up  and  forced  bladderward  by  the  enlarged  lateral  lobes.  If 
these  hypertrophied  masses  originated  from  the  median  lobe,  the  floor  of  the  urethra  would 
be  raised  up,  whereas  the  specimen  shows  the  floor  of  the  urethra  only  distorted  in  a  lateral 
.  In  „  n  ■  "^"''^  %""  '^°°J  '^  actually  depressed.  The  position  of  the  colliculus  in  this  case  is 
of\rHVp%"VoS?d1?rost1te':r  "'■  "^"'""'^  ""^'^  °"  ""'^  °P^^"''"^  Treatment 


Fig.   17. 


Photograph  of  a  perfect  example  of  a  median  lobe  enlargement  without  hypertrophy  of 
the  lateral  lobes.  (Reproduced  from  Francis  S.  Watson's  work  on  The  Operative  Treatment 
of  the  Hypertrophied  Prostate.) 


TRANSVESICAL  PROSTATECTOMY.  7 

In  this  case  the  lateral  lobes  are  distinct,  but  not  hypertrophied. 
The  specimen  shown  in  Fig.  18  shows  well  the  part  taken  by 
the  lateral  lobes  in  some  cases  of  obstructive  prostatic  over- 
growth. The  specimen  was  removed  by  the  transvesical  route, 
and  the  entire  deformed  portion  of  the  prostate  was  removed 
in  one  piece.  Fig.  18  shows  the  under  surface  of  this  pros- 
tatic mass.  A  rubber  tube  passing  through  the  specimen  indi- 
cates the  position  of  the  urethra.  At  the  top  of  the  specimen  is 
seen  a  small  collar  which  is  the  mucous  membrane  stripped 
up  from  the  internal  sphincter.  This  sphincter  could  be  appre- 
ciated by  a  finger  in  the  bladder.  Fig.  19  is  another  photograph 
of  this  same  specimen  viewed  from  the  anterior  surface,  show- 
ing, roughly,  the  course  of  the  urethra,  as  exaggerated  by  the 
furrows  produced  by  the  presence  of  the  rubber  tube  in  the 
hardened  specimen.  The  two  lateral  lobes  which  appear  like 
the  wings  of  a  butterfly  are  joined  together  across  the  median 
line  by  a  practically  normal  median  lobe  which  is  in  no  way 
hypertrophied.  The  collar  of  mucous  membrane  also  appears 
at  the  top  of  this  specimen  and  shows  the  lack  of  any  bulging 
in  the  bladder.  As  far  as  could  be  appreciated  by  the  finger, 
the  entire  prostate  was  removed  in  this  case  with  the  possible 
exception  of  the  posterior  lobe  of  the  gland  which  was  distal 
to  the  ducts,  but  the  remains  of  which  could  not  be  appreciated 
by  the  finger.  Examination  of  the  cavity  from  which  this  pros- 
tate was  removed,  made  immediately  after  the  operation, 
demonstrated  no  tissue  remaining  which  in  any  way  resembled 
prostatic  tissue.  Fig.  20  is  a  photograph  of  a  specimen  re- 
moved the  same  day  as  the  previous  specimen  and  shows  the 
prostatic  mass  as  removed  in  one  piece.  The  small  drainage 
tube  occupies  the  position  of  the  urethra  and  shows  it  distorted 
and  the  presence  of  the  greatly  enlarged  median  lobe  which 
extends  into  the  bladder  and  lifts  the  urethra  up.  The  bladder 
in  this  case  is  to  the  right  of  the  specimen.  As  one  views  the 
specimen  grossly,  it  would  look  as  if  the  entire  adenoma  were 
one  piece.  When,  however,  the  anterior  commissure  is  divided, 
the  specimen  falls  apart  and  forms  three  distinct  portions ;  the 
two  lateral  masses,  which  are  the  lateral  lobes,  are  greatly  hyper- 


8  PAUL  MONROE  PILCHER. 

trophied  and  compress  the  urethra,  the  course  of  which  is  indi- 
cated by  the  furrow  (Fig.  21).  To  the  left  in  the  upper 
quadrant  of  the  picture  is  seen  the  median  lobe  which  extends 
well  down  into  the  urethra,  well  past  the  first  portion  of  the 
lateral  lobes,  in  fact,  forming  a  wedge-shaped  lobe  between  the 
portions  of  the  lateral  lobes  which  extend  into  the  bladder. 
However,  the  specimen  clearly  shows  the  relations  of  the  two 
lateral  lobes  to  the  urethra.  Fig.  22  shows  another  view  of  this 
same  gland  which  indicates  more  clearly  the  exact  position  of 
the  urethra  and  its  relations  to  the  lateral  lobes  and  to  the 
median  lobe.  In  this  specimen  one  lateral  lobe  has  been  re- 
moved and  the  furrow,  as  indicated  in  the  specimen,  shows  the 
relation  of  the  urethra  to  both  the  lateral  and  median  lobes. 
The  lateral  lobe  forms  the  side  wall  for  over  two  inches,  while 
the  median  lobe,  passing  beneath  the  urethra,  extends  along  it 
for  an  inch  and  a  quarter. 

Our  own  deductions  are  based  primarily  on  an  analytical 
study  of  our  own  cases,  taking  into  account,  first,  the  conforma- 
tion of  the  prostatic  mass  as  presented  to  the  cystoscopist  and 
judged  by  the  eye,  and  the  mass  as  found  in  situ  at  the  time 
of  operation  and  appreciated  by  the  finger;  second,  a  careful 
determination  of  the  adenomatous  mass  in  relation  to  the  open- 
ing of  the  urethra  and  the  sphincter  vesicas;  and  third,  a  thor- 
ough gross  and  sectional  examination  of  all  our  specimens 
after  removal  by  the  transvesical  route. 

Professor  Tandler  has  not  demonstrated  conclusively  that 
the  lateral  lobes  of  the  prostate  are  compressed  and  atrophied 
by  enlargement  of  the  anatomical  median  lobe.  If  he  could 
show  us  the  various  stages  of  the  development  of  this  phenom- 
enon by  microscopical  section,  we  would  be  convinced  of  his 
argument,  but  he  has  not  presented  any  microscopical  sections 
showing  the  transition  from  the  adenoma  Involving  the  median 
lobe  and  atrophy  of  the  lateral  lobes.  Furthermore,  before  we 
could  accept  his  theory  of  the  enlargement  being  confined  only 
to  the  median  lobe,  It  would  be  necessary  to  show  that  the  ducts 
leading  from  this  lobe  were  entirely  distinct  from  the  ducts 
leading  from  the  lateral  lobes. 


Fig.  i8. 


Specimen  removed  by  transvesical  operation,  showing  under  surface  in  a  case  of  enlarge- 
ment of  both  lateral  lobes. 


Fig.    19. 


Same  specimen  as  Fig.  18.     The  anterior  commissure  divided,  showing  two  lateral  hyper- 
trophied  lobes  and  the  normal  sized  median  lobe  joining  the  two  enlarged  lobes. 


Fig.  20. 


Specimen  removed  by  transvesical  operation  showing  the  entire  prostate  removed  in  one 

piece. 


Fig.  21. 


Same  specimen  as  Fig.  20.  The  anterior  commissure  divided  allowing  the  hypertro- 
phied  right  lobe  to  drop  down,  showing  the  relation  of  the  enlarged  middle  lobe  and  the 
left  lateral  lobe  to  the  urethra.  The  middle  lobe  is  seen  to  form  the  floor  of  the  urethra  for 
a  distance  of  about  one  and  one-half  inches,  but  does  not  extend  as  far  up  on  the  urethra 
as  the  lateral  lobe. 


Fig.  22. 


Same  specimen.     Shows  this  same  condition  more  clearly. 
Fig.  23. 


A  close  view,  through  cystoscope,  of  a  dilated  ureter  opening  with  lax  walls. 


TRANSVESICAL  PROSTATECTOMY.  g 

II.    THE  CHOICE  OF  TREATMENT. 

Assuming  the  diagnosis  to  be  correct,  that  is,  that  obstruc- 
tive prostatic  disease  exists,  how  shall  we  determine  the  course 
of  treatment?  And  when  the  indication  for  prostatectomy  is 
present,  what  is  the  safest  procedure? 

I.  Palliative  Measures. — The  establishment  of  a  cathe- 
ter life,  destroying  an  obstructing  mass  by  using  the  cautery  or 
punch,  or  the  high  frequency  spark,  are  all  but  temporary  ex- 
pedients. Any  and  all  of  these  methods  may  be  used  to  insure 
the  patient's  temporary  relief,  but  invariably  the  patient  con- 
tinues to  become  more  enfeebled,  is  constantly  the  slave  of  his 
bladder,  his  mind  is  never  at  rest  and  finally,  as  a  rule,  he 
must  face  either  an  operation  or  death.  Certainly  this  fact  has 
been  most  forcibly  demonstrated  in  the  recent  survey  of  our 
non-operated  cases.  These  cases  naturally  fall  into  three 
classes,  those  in  which  the  urinary  obstruction  is  due  to  benign 
hypertrophy  of  the  prostate,  in  other  words,  a  chronic  inter- 
stitial prostatitis;  second,  those  cases  in  which  the  obstruction 
is  due  to  carcinoma  of  the  prostate ;  and  third,  tubercular  hyper- 
trophy of  the  prostate. 

In  the  first  class,  in  those  cases  in  whom  the  obstruction  has 
developed  to  that  stage  where  the  use  of  a  catheter,  either  at 
intervals  or  every  day,  has  become  necessary  to  insure  their 
comfort,  infection  sooner  or  later  takes  place,  followed  by 
sepsis,  uraemia,  etc.,  and  the  average  length  of  life  is  less  than 
three  years.  This  is  a  little  longer  than  the  average  time  found 
in  Squier's  recently  tabulated  cases.  All  of  this  time,  however, 
the  patient  lives  in  filth  and  misery  and  is  a  burden  to  himself 
and  a  trial  to  his  friends. 

In  the  second  class  of  cases,  the  unoperated  malignant 
growths  of  the  prostate,  no  average  can  be  stated  which  is  of 
much  value.  The  progress  of  cancer  in  the  prostate  is  slow 
as  a  rule,  but  where  there  is  much  obstruction  due  to  the 
growth,  the  combination  of  uraemia  and  the  effects  of  the  can- 
cer often  terminate  the  life  of  the  patient  within  a  year. 

In  the  last  28  cases  of  benign  hypertrophy  of  the  prostate, 
which  comprises  all  cases  operated  upon  within  the  last  two 


lO  PAUL  MONROE  PILCHER. 

years,  during  which  the  new  method  hereinafter  to  be  described 
has  been  followed,  we  have  secured  loo  per  cent,  recovery. 
In  the  malignant  growths  covering  the  same  period,  consisting 
of  six  cases,  there  has  been  one  death.  In  this  case  besides 
removing  the  prostate,  the  base  of  the  bladder  and  the  seminal 
vesicles  were  also  resected. 

Results. — In  the  non-malignant  cases  above  mentioned 
the  average  length  of  life  is  limited  by  old  age  and  the  various 
ills  incident  to  its  progress.  All  of  the  cases  have  had  full 
control  of  their  urine  and  they  have  returned  to  their  normal 
health  again.  Of  the  malignant  cases,  one  patient  is  living  two 
years  and  two  months  since  his  operation  and  is  now  showing 
marked  cachexia,  but  is  still  able  to  void  his  urine  without  the 
use  of  the  catheter.  A  second  patient  is  living,  one  year  and 
two  months  since  his  operation,  with  marked  symptoms  of 
carcinoma  involving  the  rectum,  but  is  still  able  to  empty  his 
bladder.  A  third  case  died  12  hours  after  the  operation.  A 
fourth  is  still  living,  four  months  after  operation,  with  no 
symptoms  as  yet  referable  to  the  bladder;  complete  control 
and  voids  normally.  The  fifth  case  was  operated  upon  two 
months  ago;  still  no  symptoms  of  return  and  voids  normally. 
The  sixth  case  is  still  in  hospital  making  a  good  recovery.  One 
case  of  tuberculosis  of  the  prostate  was  operated  upon  in  which 
the  prostate  was  removed  by  this  method.  The  patient  recov- 
ered and  is  to-day  perfectly  well,  one  year  and  four  months 
since  the  operation. 

2.  Operative  Considerations. — The  chief  indication.  If 
practitioners  and  surgeons  will  hold  in  mind  the  fact  that  the 
chief  indication  is  primarily  to  relieve  the  retention  of  urine 
rather  than  the  removal  of  the  prostate,  the  entire  subject 
of  obstructive  prostatic  disease  will  assume  a  different  aspect. 
If  we  could  dissuade  surgeons,  as  a  rule,  from  the  course  of 
immediately  taking  out  a  prostate  which  is  known  to  be  obstruc- 
tive, we  would  do  much  to  help  the  cause  of  the  prostatics. 

There  are  two  methods  of  accomplishing  the  relief  of  the 
retention  of  urine,  and  one  of  these  two  methods  should  com- 
prise the  first  step  in  every  operative  encroachment  upon  the 


TRANSVESICAL  PROSTATECTOMY.  II 

bladder  for  this  disease.  First  is  the  use  of  an  indweUing 
catheter  which  systematically  drains  the  bladder  for  a  definite 
period  of  time  until  the  kidney  has  reacted  from  the  changed 
condition.  This  method  may  also  be  used  to  clear  up  the 
cystitis.  The  second  method  is  a  suprapubic  cystostomy  and 
the  introduction  of  a  permanent  catheter  occupying  the  cystos- 
tomy wound  for  the  same  purpose  as  an  indwelling  catheter. 

Before  discussing  the  relative  values  of  these  two  methods, 
one  of  which  should  always  be  employed  before  prostatectomy 
is  considered,  I  wish  to  present  a  few  facts  which  demonstrate 
that  retention  of  urine  in  the  bladder  in  prostatic  disease  has  a 
very  distinct  and  fundamental  effect  upon  the  general  economy. 

The  Kidney  as  Affected  by  Prostatic  Hypertrophy. — 
First,  clinical  evidence:  The  clinician  will  observe,  in  cases  of 
prostatic  disease  in  which  there  is  considerable  retention  of 
urine,  that  the  most  marked  symptoms  will  be  evidences  of 
intestinal  stasis,  loss  of  appetite,  loss  of  sleep,  changes  in  tem- 
perament, mental  degeneration,  lack  of  personal  pride,  loss  of 
weight  and  a  general  deterioration  of  the  entire  organism. 
Aside  from  this,  further  examination  will  show  various  phases 
of  uraemic  poisoning;  in  many  cases  a  very  marked  increase  in 
the  secretion  of  urine  with  low  specific  gravity.  Frequently  the 
amount  of  urine  will  reach  150  ounces  in  24  hours  and  its 
specific  gravity  be  as  low  as  1002.  In  a  recent  case  the  24-hour 
record  was  over  300  ounces.  This,  of  course,  is  an  index  of 
functional  derangement  of  the  kidney.  The  rapid  disappear- 
ance of  all  these  clinical  evidences  of  disturbed  renal  function, 
which  follows  draining  of  the  bladder*,  shows  the  direct  relation 
of  cause  and  effect. 

We  have  both  acute  and  chronic,  partial  and  complete  forms 
of  obstruction. 

In  the  cases  of  chronic  partial  obstruction  it  has  been  noted 
in  general  that  the  amount  of  urine  secreted  is  increased,  pro- 
viding the  bladder  is  strong  enough  to  regularly  overcome  the 
partial  obstruction,  and  partially  empty  the  bladder  so  that 
at  no  time  the  back  pressure  from  the  bladder  is  continually 
great.    Where  the  musculature  of  the  bladder  is  not  so  strong, 


12  PAUL  MONROE  PILCHER. 

and  there  is  a  chronic  retention  of  a  considerable  amount  of 
urine  with  very  Httle  overflow,  the  amount  of  urine  secreted  will 
often  average  as  high  as  120  to  150  ounces  in  twenty-four 
hours  with  a  low  specific  gravity. 

Where  we  have  a  contracted  bladder  with  greatly  thickened 
walls,  in  which  there  is  only  a  small  amount  of  retention,  and 
the  amount  of  retained  urine  almost  entirely  fills  the  contracted 
bladder,  the  urine  is  passed  very  frequently  and  in  small 
amounts.  Such  a  bladder  may  contain  only  two  or  three  ounces 
and  is  almost  continuously  full.  Under  such  conditions  the 
kidney  seems  to  diminish  its  secretions.  The  total  amount 
secreted  in  twenty-four  hours  may  be  very  little,  finally  result- 
ing in  complete  anuria. 

The  other  cases  are  those  of  acute  retention  of  urine,  in 
which  the  kidneys  act  freely  until  the  bladder  is  filled  to  its 
capacity,  at  which  time  the  kidneys  stop  acting  entirely.  It 
must  be  remembered  that  the  bladder  will  never  rupture  from 
overdistention  due  to  accumulation  of  urine. 

Aside  from  the  clinical  evidence  of  renal  infection  and  renal 
insufficiency  already  presented,  the  most  striking  evidence  of 
renal  injury  due  to  prostatic  obstruction  is  presented  in  those 
cases  dying  from  the  disease.  Autopsy  shows  a  variety  of 
conditions  existing  in  the  kidney,  the  lesion  most  common  to 
all  being  a  hydro-ureter  beginning  immediately  above  the 
bladder,  resulting  in  various  degrees  of  hydronephrosis  and  de- 
struction of  the  kidney  parenchyma.  This  in  turn  is  influenced 
by  the  degree  and  duration  of  the  obstruction  and  in  more 
advanced  cases  is  accompanied  by  infection,  the  formation  of 
renal  calculi,  and,  in  some  cases,  by  actual  infection  and  destruc- 
tion of  the  kidney  parenchyma.^ 

To  the  mind  of  the  writer  those  lesions  are  brought  about  by 
two  mechanical  conditions:  i.  The  hypertrophy  of  the  mus- 
cular walls  of  the  bladder  through  which  the  lower  end  of  the 
ureter  passes  and,  2,  the  constant  presence  of  residual  urine 
which  helps  to  keep  the  muscles  compressed  and  forming  a 

"  Wade :    Prostatism,  Fig.  40.    March  Annals  of  Surgery,  p.  334. 


TPLANSVESICAL  PROSTATECTOMY.  I^ 

o 

chronic  obstruction  extending  over  that  portion  of  the  ureter 
which  passes  through  the  bladder  wall.  It  is  the  exceptional 
case  in  which  the  infection  is  an  ascending  one,  but  usually,  in 
my  opinion,  it  is  due  to  hematogenous  and  lymphatic  infection 
of  a  tissue  whose  resistance  has  been  greatly  lowered  by 
mechanical  obstruction. 

Second  J  objective  symptoms:  The  cystoscope  shows  that 
many  changes  have  taken  place  in  the  bladder.  First,  we  note 
that  the  muscular  walls  are  markedly  changed.  They  are 
hypertrophied  and  trabeculated,  and  false  and  true  diverticula 
are  formed,  and  occasionally  calculi  of  various  sizes  and  shapes 
are  seen.  Occasionally,  also,  the  infection  of  the  renal  pelvis 
which  follows  retention  of  urine  predisposes  to  the  formation 
of  renal  stones  which  may  be  shown  on  the  X-ray  plate. 

The  cystoscope,  as  a  rule,  shows  the  ureter  opening  raised  up 
on  a  ridge  with  the  interureteric  fold  quite  distinct.  The  ureter 
opening  in  the  majority  of  cases  is  normal  with  the  exception 
that  it  is  changed  by  the  general  muscular  hypertrophy  which 
surrounds  it.  Occasionally  the  ureter  opening  is  dilated,  as  is 
seen  in  the  accompanying  illustration  (Fig.  22,). 

Third,  the  operative  proof:  From  a  careful  study  of  a 
series  of  cases  in  which  a  preliminary  cystostomy  was  done, 
certain  phenomena  were  repeatedly  observed  which  seemed  to 
justify  us  in  dividing  the  sequelae  to  advanced  prostatism  into 
three  phases.  It  has  further  emphasized  in  our  minds  the 
peajliar  balance  existing  between  the  heart,  kidney,  secretion 
of  urine,  and  the  nervous  control  of  these  in  the  patient  who 
has  gradually  become  used  to  over-distention  of  the  bladder. 
The  pathology  of  this  condition  has  already  been  referred  to. 

We  have  learned  not  to  rely  upon  any  one  clinical  sign  or 
symptom  in  judging  the  fitness  of  the  patient  for  operation. 
We  have  learned  that  the  balance  between  the  various  elements 
of  the  system  are  so  adjusted  that  a  disturbance  of  one  element 
will  bring  to  light  weakness  in  some  of  the  other  elements  which 
has  not  been  suspected,  for  example,  the  phthalein  test.  This 
may  be  very  deceptive.  The  patient  may  show  60  to  70  per 
cent,  of  excretion  of  phthalein  in  two  hours  before  anything 


14 


PAUL  MONROE  PILCHER. 


has  been  done  to  relieve  the  retention  of  urine.  But  disturb 
the  retained  urine  in  the  bladder  and  all  of  the  other  elements  of 
the  system  are  thrown  into  confusion.  The  back  pressure  is  re- 
lieved; decompression  of  the  kidney  follows;  swelling  and  con- 
gestion of  the  kidney  takes  place;  and  the  functional  capacity 
of  the  kidney  immediately  drops  to  a  very  low  point.  The  out- 
ward signs  of  the  derangement  of  this  unbalanced  kidney  are 
very  evident.  This  is  the  second  phase.  It  is  our  belief  that 
many  of  the  cases  which  have  died  following  operation  are  the 
result  of  a  lack  of  appreciation  of  this  second  phase  of  a  renal 
disturbance  in  prostatics.  Many  deaths  have  been  reported 
on  the  third  to  the  fifth  day  following  a  one-step  prostatectomy, 
when  the  patient  was  seemingly  doing  well ;  but  when  we  add 
the  phenomena  of  the  second  phase  to  the  shock  of  the  major 
operation  with  its  loss  of  blood  and  the  depressing  effect  of  the 
general  anaesthetic,  it  can  be  easily  appreciated  why  these 
deaths  take  place,  and  many  will  agree  that  the  overtaxed  heart 
and  the  system  overloaded  with  toxins  which  the  kidneys  should 
separate  from  the  blood  are  the  cause  of  death.  Our  extended 
observations  have  shown  us  that  nearly  every  prostatic  will 
present  these  three  phases,  and  this  fact  has  influenced  us  ver)^ 
greatly  in  favor  of  the  two-stage  operation  in  every  case  of 
benign  hypertrophy. 

III.    THE  THREE  PHASES, 

The  results  of  our  observations  are  graphically  shown  on 
the  accompanying  chart.  Fig.  24,  which  shows  the  average 
condition  which  prevails  in  many  advanced  cases  of  obstructive 
hypertrophy  of  the  prostate. 

The  First  Phase. — For  the  first  day,  the  day  on  which  the 
suprapubic  cystostomy  is  done,  the  blood-pressure  frequently 
registers  from  200  to  220  mm.  of  mercury ;  the  urinary  output 
for  24  hours  will  average  from  70  to  120  ounces;  the  phenol- 
sulphone-phthalein  test  will  frequently  average  above  60  per 
cent,  in  two  hours  and  the  urine  will  show  only  a  trace  of  albu- 
min. If  these  conditions  are  considered  by  themselves,  they 
will  give  us  a  false  impression  of  the  actual  condition  of  the 


TRANSVESICAL  PROSTATECTOMY. 
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Chart  showing  the  three  phases  following  suprapubic  cystostomy  in  an  advanced  case 
of  obstruction  due  to  prostatic  hypertrophy. 

First  phase:  Includes  the  first  and  second  day,  the  suprapubic  cystostomy  being  done 
on  the  first  day.  If  one  would  observe  this  chart  excluding  the  following  days,  the  conditions 
would  seem  to  be  favorable  for  any  operative  encroachment.  See  page  514.  If  taken  alone, 
this  surely  would  seem  to  indicate  a  safe  surgical  risk. 

Second  phase:  This  phase  extends  over  the  third,  fourth,  fifth  and  sixth  days  after  a 
suprapubic  cystostomy.    It  shows  a  very  marked  decrease  in  urinary  output  during  that  time, 

(Legend  continued  on  next  page.) 


1 6  PAUL  MONROE  PILCHER. 

patient.  For  example,  if  the  patient's  blood-pressure  registered 
200,  was  passing  90  ounces  of  urine  in  24  hours  with  low 
specific  gravity  and  with  only  a  trace  of  albumin,  we  would  be 
rather  suspicious  of  the  functional  capacity  of  the  kidneys. 
But  when  we  make  a  phenol-sulphone-phthalein  test,  and  find 
that  the  output  in  two  hours  is  60  per  cent,  or  more,  it  rather 
leads  us  to  believe  that  the  actual  functional  capacity  of  the 
kidney  is  greater  than  the  specific  gravity  of  the  given  specimen 
would  lead  us  to  believe. 

The  Second  Phase. — A  second  glance  at  the  chart  will  show 
a  very  different  condition  existing  on  the  third  or  fourth  day 
after  the  bladder  has  been  opened  and  drained.  Here  we  see 
a  lowered  blood-pressure,  probably  between  170  and  180.  The 
urinary  output  has  suddenly  dropped  to  from  15  to  20  ounces 
in  24  hours ;  the  amount  of  albumin  in  the  urine  has  increased 
enormously  and  often  the  urine  itself  boils  almost  solid.  On 
the  third  to  fourth  day,  the  phenolphthalein  test  shows  the 
actual  functional  capacity  of  the  kidney  at  this  most  critical 
time  to  be  only  75  per  cent.  This,  then,  is  the  change  which 
has  taken  place  simply  following  a  suprapubic  drainage  of  the 
bladder  without  any  loss  of  blood  or  other  surgical  shock  due 
to  anaesthesia  or  prolonged  manipulation.  Add  to  this,  then, 
the  shock  of  a  prostatectomy  with  its  general  anaesthesia,  a 
very  considerable  loss  of  blood  and  the  shock  consequent  to 
pain,  and  one  does  not  wonder  that  so  many  cases  have  died  on 
the  third,  fourth  and  fifth  day  from  no  apparent  cause  which 
could  be  demonstrated. 

The  Third  Phase. — Passing  on  then  to  the  third  phase  of 

a  large  increase  in  the  amount  of  albumin  present,  but  most  important  of  all  the  drop  in 
functional  capacity  of  the  kidney  from  60  to  15  per  cent. 

Third  phase:  Showing  the  reaction  and  the  recovery  of  the  kidney  after  ten  days. 
Blood-pressure  170,  urinary  output  averaging  50,  phthalein  test  50  per  cent.,  and  a  smaller 
amount  of  albumin  present  in  the  urine.  Comparing  this  phase  with  the  first  phase  we  find 
a  lower  blood-pressure,  a  normal  urinary  secretion  with  an  increased  specific  gravity,  a 
lowered  functional  capacity  of  the  kidne}^  as  attested  by  the  phenolphthalein  test  and  a 
larger  amount  of  albumin  present  in  the  urine  than  during  the  first  phase.  When,  however, 
the  reaction  from  this  phase  following  enucleation  of  the  prostate  is  considered,  what  a 
much  better  combination  of  circumstances  exist  in  this  phase  than  in  the  first  phase.  Follow- 
ing prostatectomy,  the  blood-pressure  falls  still  lower,  due  to  the  loss  of  blood.  The  urinary 
output  decreases  most  markedly  during  the  first  24  hours,  but  recovers  rapidly  until,  on  the 
third  day,  it  is  practically  normal.  The  phthalein  test  shows  lessened  reaction,  but  it  never 
drops  as  low  as  was  found  in  the  second  phase  after  suprapubic  cystostomy,  so  that  so  per 
cent,  according  to  the  phthalein  test  in  the  third  phase  shows  a  very  much  greater  relative 
functional  capacity  than  60  per  cent,  in  the  first  phase.  This  we  consider  a  point  of  very 
great  importance.    The  amount  of  albumin  following  the  operation  is  an  unknown  quantity. 


TRANSVESICAL  PROSTATECTOMY. 


17 


the  condition  following  drainage  of  the  bladder,  we  find  in  the 
average  case  that  on  the  seventh  to  tenth  day  the  blood-pressure 
has  decreased  to  from  160  to  170  mm.,  the  urinary  output  has 
increased  to  from  40  to  50  ounces  in  24  hours,  the  phenol- 
phthalein  test  shows  a  reaction  of  the  kidney  from  an  output  of 
15  per  cent,  to  an  output  of  50  per  cent.,  and  the  amount  of 
albumin  contained  in  the  urine  has  decreased  very  markedly, 
but  still  shows  a  small  amount  present,  more  than  was  present 
before  the  cystostomy  and  very  much  less  in  amount  than  was 
found  on  the  third  or  fourth  day. 

Now  if  the  prostatectomy  is  performed,  the  effect  upon  all 
these  phenomena  is  quite  different  than  was  found  after  the 
preliminary  cystostomy.  The  blood-pressure  falls  still  lower, 
the  urinary  output  decreases  very  little ;  the  functional  capacity 
of  the  kidney  does  not  fall  more  than  ten  points ;  it  is  difficult 
to  ascertain  the  amount  of  albumin  present  in  the  urine  on 
account  of  the  presence  of  the  wound  in  the  bladder,  but  at  no 
time  is  it  as  great  as  was  found  on  the  third  or  fourth  day 
after  the  cystostomy  was  performed. 

By  following  this  method  we  entirely  avoid  the  second 
phase  after  the  prostatectomy. 

This  conclusion  is  based  upon  the  study  of  our  last  28  suc- 
cessive cases,  all  of  which  have  been  operated  upon  after  this 
method  and  all  of  which  have  recovered.  It  must  be  remem- 
bered that  the  second  phase  will  last  from  a  day  or  two  to  many 
weeks,  and  if  the  reaction  to  the  third  phase  docs  not  take  place 
within  ten  days  to  two  weeks,  the  surgeon  shotdd  not  under 
any  circumstances  be  persuaded  to  remove  the  prostate,  because 
if  he  does  the  chances  are  very  much  in  favor  of  a  fatal  out- 
come. In  one  of  our  cases  a  gastric  uraemia  developed  on  the 
third  or  fourth  day  and  it  was  impossible  to  remove  the  prostate 
for  over  five  weeks.  At  the  end  of  that  time  the  third  phase  of 
the  phenomenon  appeared  and  the  prostate  was  removed  with- 
out any  shock  to  the  patient,  followed  by  uncomplicated 
recovery. 

All  clinical  observers  naturally  realize  that  the  different 
stages  vary  in  many  cases  as  to  their  extent  and  their  duration. 


1 8  PAUL  MONROE  PILCHER. 

This  point  may  best  be  emphasized  by  the  following  illus- 
trative cases : 

Case  I. — Diagnosis:  Hypcrtrophied  prostate;  complete  ob- 
struction; vesical  calculus;  mitral  insufliciency ;  chronic  interstitial 
nephritis;  double  inguinal  hernia. 

Condition  on  entrance  to  hospital  July  14,  1913 :  A  large 
framed  man,  eigJity-tzuo  years  of  age,  who  has  led  an  active  sea- 
faring life.  For  ten  years  has  had  increasing  frequency  of  urina- 
tion and  for  two  years  has  used  catheter  daily  for  the  removal  of 
residual  urine  ;  nozv  depends  entirely  upon  a  catheter  zvhich  he  uses 
every  four  hours.  The  use  of  the  catheter  is  becoming  increas- 
ingly difficult  and  painful  and  has  already  provoked  several  attacks 
of  double  epididymitis.  There  is  present  a  moderate  cystitis. 
There  are  evidences  of  a  generalized  arteriosclerosis  with  some 
mitral  insufficiency  and  a  moderate  degree  of  chronic  interstitial 
nephritis.  He  has  also  a  double  inguinal  hernia.  Notwithstand- 
ing these  many  physical  defects,  he  still  presents  evidences  of  con- 
siderable vital  force  and,  in  the  opinion  of  the  surgeons,  is  a  rea- 
sonably fair  operative  risk  in  the  face  of  the  marked  urinary  crises 
which  are  developing.  Blood-pressure,  220  mm. ;  urinary  output, 
80  oz. ;  phthalein  test,  57  per  cent. ;  albumin,  a  trace. 

First  Operation. — On  July  15,  1913,  a  preliminary  suprapubic 
cystostomy  was  done  by  Dr.  L.  S.  Pilcher  under  local  cocaine 
anaesthesia,  using  i  per  cent,  solution  of  cocaine. 

The  bladder  was  exposed  in  the  usual  manner  without  com- 
plaint from  the  patient.  Upon  opening  the  bladder  a  medium- 
sized  uric  acid  calculus  the  size  of  a  lima  bean  was  detected  and 
removed.  A  polypoid  development  of  the  middle  lobe  of  the  pros- 
tate perceived.  A  Pezzer  catheter  was  secured  in  the  bladder  and 
the  wound  sutured.  Patient  sustained  no  shock  from  the  opera- 
tion. During  the  following  week  he  remained  very  comfortable. 
Urinary  output  dropped  to  30  oz. ;  phthalein  test  to  18  per  cent., 
etc.  (see  Fig.  25).  There  was  a  gradual  lessening  in  the  blood- 
pressure  and  a  notable  improvement  in  his  general  well-being.  A 
phenolphthalein  test  showed  a  steady  increase  in  the  renal  activity. 
Consulting  the  accompanying  chart.  Fig.  25,  it  will  be  seen 
that  the  blood-pressure  had  been  reduced  to  170  and  the  functional 
activity  of  the  kidneys  had  reacted  from  the  first  period  of  depres- 
sion.   The  patient's  condition  was  very  satisfactory,  despite  his 


TRANSVESICAL  PROSTATECTOMY. 
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The  Three  Phase  Cycle. 

Chart  of  Case  I.  Showing  the  three  phases  in  a  patient  82  years  of  age.  Note  the 
marked  difference  between  the  three  phases — especially  the  drop  from  57  per  cent,  to  18 
per  cent,  in  the  renal  efficiency  and  the  large  increase  in  amount  of  albumin.  Prostate 
enucleated  during  third  phase.     Recovery. 

age  of  82  years  and  his  mitral  insufficiency  and  chronic  interstitial 
nephritis.  It  was,  therefore,  deemed  proper  to  attempt  enuclea- 
tion of  his  prostate. 


20  PAUL  MONROE  PILCHER. 

Second  Operation. — Transvesical  prostatectomy.  Under  ether 
anaesthesia,  the  finger  was  passed  through  the  suprapubic  opening 
and  without  removing  any  of  the  sutures  the  prostate  was  enucle- 
ated in  three  minutes.  Some  packing  of  the  prostatic  pouch  was 
necessary  to  control  a  moderate  hemorrhage.  There  was  no 
shock  following  the  operation.  Draining  tube  and  packing  re- 
moved in  24  hours  and  a  Pezzer  catheter  introduced.  The  Pezzer 
catheter  removed  on  the  fourth  day  followed  by  uninterrupted 
healing  of  the  wound  and  full  restoration  of  function.  Six  months 
after  the  operation  the  patient  is  quite  well  and  is  urinating  nor- 
mally. 

It  seems  quite  evident  to  us  that  it  w^as  safer  ten  days 
after  the  primary  operation  to  remove  the  prostate  than  it 
would  have  been  at  the  time  of  the  primary  operation.  With 
the  blood-pressure  of  170  instead  of  220,  with  the  kidneys  re- 
lieved of  the  disorganization  incident  to  retention  of  urine, 
and  with  a  well-balanced  functional  activity,  the  prostatectomy 
could  be  undertaken  without  danger  to  the  patient.  In  our 
series  of  cases  the  depression  which  occurs  from  the  third  to 
the  sixth  day  has  been  so  constant  that  it  is  a  real  factor  to  be 
reckoned  with  in  all  these  cases,  and  it  is  our  belief  that  no 
prostate  should  be  removed  until  this  period  of  reaction  has 
been  passed. 

In  some  cases  the  second  stage  lasts  two,  three,  four  or  more 
weeks.  During  this  period  after  the  suprapubic  cystostomy 
all  of  the  clinical  features  of  the  case  preclude  the  possibility  of 
a  prostatectomy  and  not  until  a  fully  developed  third  stage 
appears  should  the  prostate  be  removed.  The  following  case 
in  which  the  patient  developed  a  gastric  uraemia,  and  massive 
oedema  of  the  legs,  will  serve  as  an  example. 

Case  II. — Diagnosis:  Obstructive  hypertrophy  of  prostate; 
gastric  urccmia.  The  patient  was  admitted  May  9,  1913.  General 
health  good.  Considerable  obstruction.  No  symptoms  of  kidney 
trouble  excepting  a  slight  amount  of  albumin  which  was  present. 

First  Operation. — Suprapubic  cystostomy;  Pezzer  catheter. 
May  10,  1913,  operation  quickly  accomplished  under  local  anaes- 
thesia. The  day  following  operation  passed  24  ounces  of  urine, 
clear,  large  amount  of  albumin  present;  26  hours  after  operation 


TRANSVESICAL  PROSTATECTOMY.  2 1 

began  to  vomit ;  8  hours  after  operation  hiccoughs  began  and  con- 
tinued intermittently  for  24  hours.  Second  24  hours  urinary  out- 
put dropped  to  2.^  ounces,  still  clear;  vomiting  continued;  urine 
almost  solid  with  albumin.  Third  24  hours  some  nausea,  no 
vomiting.  Fourth  24  hours  vomiting  recommenced.  Hiccoughs 
lasted  for  14  hours,  quite  restless.  Urine  became  bloody,  almost 
solid  with  albumin — 29  ounces  in  24  hours.  Fourth  day  very 
sleepy,  hiccoughs  continuing,  legs  showed  slight  swelling,  urine 
bloody.  Fifth  day  slight  hiccough,  urine  clearer,  sat  up.  Patient 
showed  a  gradual  improvement  with  the  exception  of  the  swelling 
in  his  legs,  which  increased  so  that  both  legs  soon  became  very 
badly  swollen. 

Coincident  with  this  no  phenolphthalein  test  was  made  on 
account  of  the  large  amount  of  blood  and  albumin  present.  June  2, 
phenolphthalein  test  showed  30  per  cent,  excretion  the  first  two 
hours ;  June  9,  one  week  later,  showed  22  per  cent,  excretion  first 
two  hours;  June  15  showed  21  per  cent.;  July  i,  phenolphthalein 
test  showed  the  excretion  to  be  48  per  cent,  in  two  hours.  The 
patient's  general  condition  showed  a  coincident  improvement, 
swelling  of  the  legs  entirely  disappeared,  the  amount  of  albumin 
in  the  urine  very  greatly  decreased  so  a  further  operation  was 
deemed  advisable. 

Second  Operation. — Transvesical  prostatectomy.  July  5, 
1913.  Suprapubic  catheter  removed  and  with  the  finger  passed 
into  the  bladder  through  the  suprapubic  opening  the  prostate  was 
easily  removed.  There  was  considerable  hemorrhage  which  neces- 
sitated the  introduction  of  packing.  Reaction  from  the  operation 
was  very  slight.  Twenty-four  hours  after  operation  was  sitting 
up  in  bed ;  48  hours  after  operation  the  drainage  tube  was  re- 
moved from  the  wound  and  Pezzer  catheter  re-inserted ;  59  ounces 
were  collected  through  this  catheter  during  the  24  hours,  with 
hardly  any  leakage.  On  the  fifth,  sixth  and  seventh  days  he 
evidenced  some  stomach  irritability  and  vomited  a  little,  but  the 
attack  passed  off  quickly.  On  the  ninth  day  began  to  urinate  a 
little.  Wound  healed  promptly  and  the  patient  was  discharged 
cured  August  2. 

It  is  not  only  the  kidney  and  its  function  which  must  be 
considered,  but  it  may  be  that  it  is  the  heart  that  is  the  weak 
link  in  the  chain,  and  in  order  to  ensure  a  safe  operation  the 


22 


PAUL  MONROE  PII-CHER. 
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The  Three  Phase  Cycle.     Prolonged  Second  Stage. 

First  phase:  Aside  from  the  large  amount  of  urine  passed,  the  patient's  condition  was 
almost  ideal.  ,,     1    j 

Second  phase :  Which  followed  the  suprapubic  cystostomy  was  unusually  severe.  Marked 
diminution  in  the  amount  of  urine.  Urine  boiled  almost  solid.  Gastric  uraemia  supervened. 
Enormous  swelling  of  the  legs.  Patient  in  desperate  condition.  At  the  end  of  51  days,  how- 
ever, all  of  the  uraemia  symptoms  had  disappeared.     Amount  of  urine  passed  was  normal. 

Third  phase :  At  end  of  50  days  phthalein  test  showed  48  per  cent.  Urme  showed  very 
small  amount  of  albumin.  Patient's  general  condition  satisfactory.  Prostate  enucleated 
with  hardly  any  post-operative  reaction.     Patient  made  perfect  recovery. 


TRANSVESICAL  PROSTATECTOMY. 


'23 


kidney  must  be  in  the  best  possible  condition  before  the  enuclea- 
tion is  undertaken,  for  if,  with  a  failing,  dilating  heart  the  renal 
function  fails,  there  is  little  hope  for  the  patient's  recovery. 
The  following  case  illustrates  this  point : 

Case  III. —  (Lynch.)  Patient  was  a  man  whose  actual  age 
was  sixty-five  years  although  his  appearance  was  that  of  a  man 
of  about  eighty.  For  two  years  he  had  been  struggling  against 
the  ravages  of  prostatic  disease  and  had  gradually  become  emaci- 
ated. Was  rapidly  losing  his  strength  and  had  already  lost  his 
appetite.  He  had  been  catheterized  frequently,  but  this  had  ceased 
to  give  relief  and  at  the  time  of  his  examination  was  passing  his 
water  every  15  to  20  minutes  day  and  night.  As  the  result  of  a 
metal  instrument  being  passed  into  the  urethra  he  developed  an 
acute  retention  with  bleeding  into  the  bladder.  When  seen  by 
me  he  was  in  greatest  distress  and  the  bladder  dilated  up  to  the 
umbilicus.  His  pulse  was  small  and  weak.  He  was  in  consider- 
able shock. 

First  Operation. — Suprapubic  cystostomy.  He  was  hastened 
to  the  hospital  and  immediately  the  bladder  was  opened  under 
local  anaesthesia,  and  a  large  amount  of  blood  clot  and  urine  were 
brought  away  and  a  Pezzer  catheter  sutured  into  the  bladder  and 
the  wound  closed  around  it. 

The  patient  reacted  very  well  from  the  operation.  The  fol- 
lowing day  his  temperature  reached  102°,  his  pulse  100,  urinary 
output  averaged  25  ounces.  Renal  sufficiency  as  shown  on  accom- 
panying chart,  which  was  69  per  cent,  of  phenolphthalein  excreted 
during  the  first  two  hours  immediately  after  the  operation,  dropped 
on  the  third  day  to  20  per  cent,  in  two  hours  under  the  same  con- 
ditions. His  pulse  was  weak  and  soft  but  not  very  rapid.  His 
general  condition  was  good.  One  week  later  the  phenolphthalein 
test  showed  an  elimination  of  48  per  cent,  in  two  hours  (Fig.  27). 
Two  days  after  this,  when  examined,  his  condition  was  consid- 
ered proper  for  operation,  and  under  ether  anaesthesia  this  was 
accomplished. 

Second  Operation. — Enucleation  of  prostate.  Time  of  enuclea- 
tion i^  minutes.  Control  of  hemorrhage,  which  was  consider- 
able, by  packing  as  above  described.  The  day  following  the  oper- 
ation patient's  condition  good.  Packing  and  drainage  tube  re- 
moved.   Pezzer  catheter  inserted.    Urinary  conditions  good.     On 


24 


PAUL  MONROE  PILCHER. 


third  and  fourth  days  very  considerable  cardiac  insufficiency,  pulse 
extremely  weak,  intermittent  and  general  weakness  (see  chart. 
Fig,  28)  ;  temperature  101.8°,  pulse  130,  respirations  40.    Under 


Fig.  27. 




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proper  medication  the  conditions  gradually  returned  to  normal, 
which  they  reached  on  the  fourth  day.  However,  this  chart  will 
show  the  dangerous  reaction  following  the  operation  which,  if  it 
had  occurred  coincident  with  the  shock  of  the  primary  operation 


TRANSVESICAL  PROSTATECTOMY. 


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26  PAUL  MONROE  PILCHER. 

with  a  very  marked  decrease  in  the  renal  sufficiency,  the  patient 
would  probably  have  died  on  the  second  or  third  day.  As  it  is 
the  patient  recovered  entirely ;  he  passed  his  urine  by  the  urethra 
on  the  ninth  day,  and  the  wound  was  closed  completely  on  the 
twenty-second  day.     His  present  condition  is  satisfactory. 

As  already  referred  to,  in  cases  of  enormous  dilatation  of 
the  bladder  with  oedema  of  the  legs,  scrotum,  etc.,  the  three- 
phase  cycle  shows  a  remarkable  curve  when  traced  on  the  chart. 
The  accompanying  diagram,  Fig.  29,  shows  the  condition 
existing  in  a  patient  still  under  our  care.  During  the  first  24 
hours  the  patient  passed  249  ounces  of  urine,  a  catheter  being 
used  to  withdraw  the  amount  in  small  quantities  and  never 
emptying  the  bladder,  that  viscus  being  continuously  dilated  as 
high  as  the  umbilicus.  On  the  second  day  more  urine  was 
withdrawn  at  a  time  and  the  urinary  output  was  308  ounces, 
specific  gravity  1002.  Following  the  chart  it  will  be  seen  that 
gradually  the  urinary  amount  decreased  and  that  on  the  fourth 
day  the  bladder  was  completely  emptied  for  the  first  time  by 
catheter,  the  amount  passed  during  the  24  hours  being  about 
120  ounces.  This  modified  second  phase  shows  a  preliminary 
rise  and  the  enormous  output  of  urine  would  unquestionably 
have  overwhelmed  the  patient  had  a  prostatectomy  been  done, 
or  even  a  suprapubic  cystostomy. 

Fig.  30  is  the  pulse  chart  of  the  same  patient  and  shows  the 
remarkable  effect  the  condition  had  upon  the  action  of  the 
heart.  On  the  twelfth  day  the  phthalein  test  showed  a  40  per 
cent,  output,  but  the  pulse  was  extremely  unreliable.  Five 
days  after  the  suprapubic  cystostomy  the  phthalein  test  showed 
an  output  of  67  per  cent,  and  the  pulse  at  that  time  would  not 
permit  a  prostatectomy.  In  fact,  with  a  heart  so  badly  damaged 
and  a  kidney  which  had  been  exposed  to  so  much  pressure,  the 
date  of  the  prostatectomy  must  be  put  ofif  for  some  weeks. ^ 
Other  cases  show  only  a  mild  degree  of  depression  in  the  second 
phase  and  it  would  undoubtedly  have  been  perfectly  safe  to 
remove  the  prostate  at  the  first  operation,  but  as  yet  I  have  not 

"  Thirty-eight  days  after  the  cystostomy  the  prostate  was  removed  and 
the  patient  has  made  a  good  recovery. 


TRANSVESICAL  PROSTATECTOMY. 
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umbilicus.  Patient  in  collapse.  Partial  decompression  of  kidney  developed  urinary  output 
of  308  ounces  of  urine  in  24  hours.  The  second  phase  showed  a  gradual  drop  in  urinary 
output,  with  a  very  marked  increase  in  the  amount  of  albumin.  Suprapubic  cystostomy 
on  twelfth  day  showed  very  slight  reaction  from  kidney.  For  the  first  twelve  days,  urine 
was  removed  by  catheter. 


28 


PAUL  MONROE  PILCHER. 


been  able  to  tell  which  cases  fall  within  this  class  until  after  the 
cystostomy  has  been  performed. 

How  shall  we  decide,  then,  when  it  is  safe  to  remove  the 
prostate  in  a  given  case? 

First,  our  judgment  is  based  on  the  general  condition  of 
the  patient.  When  his  appetite  returns  and  his  sleep  becomes 
normal,  when  his  temperature,  pulse  and  respiration  are  nor- 

FiG.  30. 


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Pulse  chart  of  same  patient  whose  urine  chart  is  shown  in  Fig.  29.  Partial  emptying  of 
the  bladder  caused  pulse  to  rise  to  iSO  beats  per  minute.  On  the  eleventh  day  heart  action 
changed  suddenly,  as  indicated  on  the  chart,  and  its  rhythm  and  rate  were  very  irregular. 
The  heart  balance  was  gradually  established  and  the  suprapubic  cystostomy  did  not  disturb 
it  very  much. 

mal,  and  when  the  renal  output  has  returned  to  normal  limits, 
we  consider  these  a  fair  index  of  the  general  physical  well-being 
of  the  patient. 

Second,  we  do  not  advise  prostatectomy  until  all  the  gross 
ursemic  and  nephritic  symptoms  have  disappeared.  A  moder- 
ate amount  of  albumin  in  the  urine  is  no  contra-indication. 
The  condition  of  the  blood-pressure  is  also  a  valuable  index. 

Third,  the  phenolphthalein  test  is  of  value  only  as  taken 
in  connection  with  other  signs.  In  the  first  place,  one  must 
consider  the  results  of  the  phthalein  test  before  the  preliminary 
cystostomy ;  then  the  phthalein  test  taken  on  the  second,  third 


TRANSVESICAL  PROSTATECTOMY. 


29 


or  fourth  day,  and  third,  the  functional  reaction  of  the  kidney 
to  this  test  at  the  end  of  a  week  or  ten  days.  It  is  a  mistake  to 
rely  entirely  upon  this  test,  especially  before  the  cystostomy 
has  been  done.  For  example,  the  test  may  show  excretions 
of  more  than  50  per  cent,  in  the  first  two  hours  before  the 
preliminary  cystostomy,  but  the  reaction  may  drop  on  the 
second  or  third  day,  after  relief  of  the  retention  of  urine,  to 
below  15  per  cent.,  which  is  a  true  index  of  the  functional 
capacity.  When,  however,  the  period  of  depression  is  passed 
and  the  reaction  returns  to  50  per  cent,  after  the  retention  of 
urine  has  been  relieved,  this  then  becomes  a  fair  index  of  what 
we  can  expect  the  kidney  to  do  after  the  prostate  has  been 
removed. 

Catheter  Drainage  of  the  Bladder. — There  are  some 
cases  in  which  catheter  drainage  of  the  bladder  must  be  used 
as  a  preliminary  to  the  suprapubic  cystostomy,  such  as  cases 
where  there  is  an  enormous  distention  of  the  bladder  with 
oedema  of  the  legs,  scrotum,  and  penis  due  to  pressure.  If  a 
cystostomy  is  done  and  all  of  the  urine  is  withdrawn  at  one  time 
from  the  bladder,  the  shock  and  decompression  of  the  kidney 
thus  occasioned  may  bring  on  a  fatal  uraemia  or  a  fatal  hemor- 
rhage. One  such  case  was  seen  by  the  writer  at  the  Jewish 
Hospital  in  Brooklyn  where  the  bladder,  which  was  enormously 
distended,  was  suddenly  emptied;  the  patient  promptly  died. 
A  second  case  under  the  care  of  the  writer  at  St.  John's  Hospi- 
tal, in  which  72  ounces  of  urine  was  withdrawn  from  the  blad- 
der, was  followed  by  a  dangerous  hemorrhage  into  the  bladder. 

1.  Indications  for  Catheter  Drainage. — Some  operators 
prefer  to  use  catheter  drainage  for  a  week  preparatory  to 
every  transvesical  prostatectomy.  It  is  always  indicated  in 
cases  where  the  residual  urine  amounts  to  30  ounces  or  over. 

2.  Dangers. — Sudden  withdrawal  of  all  of  the  urine  may 
cause  death  from  shock,  ursemia  or  hemorrhage.  The  presence 
of  a  catheter  in  the  urethra  may  occasion  infection,  and  in 
a  number  of  reported  cases  death  has  followed  its  use. 

3.  General  Rules. — If  catheter  drainage  is  established,  the 
bladder  should  not  be  emptied  all  at  once,  but  the  urine  grad- 


30  PAUL  MONROE  PILCHER. 

ually  withdrawn  and,  depending  upon  the  amount  present  and 
the  amount  secreted  by  the  kidney,  the  amount  drawn  should  be 
regulated. 

It  is  an  interesting  fact  that  the  control  of  the  amount  of 
residual  urine  in  cases  of  enormous  distention  of  the  bladder 
will  regulate  the  output  of  urine  through  the  kidney.  In  con- 
nection with  these  cases  no  drugs  should  be  given  to  stimulate 
the  heart  or  change  its  action  until  there  is  some  very  absolute 
indication  for  the  same,  for  harm  may  be  done,  preventing  the 
establishment  of  a  normal  balance,  as  the  heart  adjusts  itself  to 
the  new  conditions  found  in  the  kidney. 

IV.    SUPRAPUBIC   CYSTOSTOMY. 

First  step,  preparation  of  the  patient.  Skin,  usual  iodine 
preparation.  Anaesthesia,  novocaine  2  per  cent,  by  preference. 
Incision,  vertical. 

Technic  of  Operation. — Usual  incision  beginning  just 
above  the  pubis  is  made  through  the  skin  and  superficial  fascia. 
The  sheath  of  the  rectus  is  divided  in  the  median  line,  the 
recti  muscles  are  separated,  exposing  the  prevesical  fat  and 
fascia.  The  muscles  are  held  apart  by  a  specially  devised 
retractor,  modified  from  the  Mayo-Collins  appendectomy  re- 
tractor. The  advantage  of  this  retractor  is  that  the  curved 
blades  are  in  a  straight  line  at  the  point  where  they  enter 
between  the  muscles,  and  after  they  are  entered  they  present  a 
concave  surface  to  the  muscular  face  which  they  wish  to 
retract,  which  keeps  them  from  slipping  out  of  the  wound. 
Then  the  third  arm  of  the  retractor  is  placed  later.  When 
the  prevesical  space  has  been  exposed,  the  finger  is  entered 
until  it  reaches  the  superior  surface  of  the  symphysis.  With 
this  as  a  landmark,  the  finger  covered  with  gauze  is  used  to  strip 
the  fascia  and  lymphatic  tissue  from  the  anterior  wall  of  the 
bladder.  It  is  often  of  advantage  to  have  the  bladder  partially 
filled  with  water,  for  then  it  is  somewhat  easier  to  clean  off 
the  anterior  surface  of  the  bladder  with  the  finger.  This 
stripping  away  of  the  tissue  with  the  finger  is  carried  up  to  the 
peritoneal  fold.     The  peritoneum  is  not  disturbed  unless  it 


TRANSVESICAL  PROSTATECTOMY. 


31 


reaches  far  down  over  the  anterior  surface  of  the  bladder. 
If  this  is  so,  the  peritoneum  is  stripped  up  somewhat.  With 
the  bladder  surface  freely  exposed,  the  third  arm  of  the  re- 
tractor is  placed  over  the  bit  of  gauze  to  hold  up  the  fat  covering 
the  peritoneal  fold. 

Securing  the  Bladder. — To  hold  the  bladder  in  place  a 
silverized  catgut  retention  suture  is  passed  through  the  wall  of 

Fig.  31. 


Second  step  in  the  preliminary  cystostomy.  The  bradder  wall  is  seen  exposed  and  the 
position  of  the  incision  is  indicated  near  the  fold  of  the  peritoneum.  The  two  stay  sutures 
are  in  place  and  hold  the  bladder  wall  up.  As  soon  as  these  sutures  have  been  introduced 
the  fluid  is  withdrawn  from  the  bladder. 


the  bladder  near  the  point  at  which  the  bladder  is  to  be  opened 
(Fig.  31).  The  water  is  then  withdrawn  from  the  bladder 
through  the  catheter  and  the  bladder  washed  clean.  Then 
holding  the  wall  of  the  bladder  out  through  the  abdominal 
wound,  a  knife  is  thrust  into  the  bladder.  The  knife  is  with- 
drawn and  the  finger  enters  the  bladder  and  examines  the  in- 
terior of  the  bladder  to  determine  the  presence  of  stone  or 


32 


PAUL  MONROE  PILCHER. 


any  foreign  body.  A  foreign  body,  if  present,  is  then  removed. 
The  condition  of  the  prostate  and  its  conformation  and  gen- 
eral character  is  then  studied  with  the  finger.  The  only  point 
at  which  the  patient  will  complain  of  pain  is  when  dragging 
on  the  bladder  wall  or  when  examining  the  bladder  with  the 
finger  through  the  bladder  wound.  Examination  of  the  in- 
terior of  the  bladder  can  be  done  quickly.  The  finger  is  then 
withdrawn  and  a  Pezzer  catheter  is  inserted  into  the  bladder 
wound  (see  Figs.  32  and  33). 

The  Point  at  Which  the  Bladder  is  to  be  Opened. — Incision 
into  the  bladder  is  made  as  near  the  peritoneal  fold  as  possible, 
for  healing  takes  place  more  rapidly  at  this  point,  and  when  a 
fistula  is  formed,  the  urine  enters  the  fistula  less  easily  at  this 
point. 

Draining  the  Bladder. — The  Pezzer  catheter,  as  mentioned 
before  (Fig.  33),  is  fixed  in  the  anterior  wall  of  the  bladder, 
then,  using  the  same  suture  that  was  placed  for  the  retraction 
suture,  a  purse-string  is  made  in  the  bladder  wall  around  the 
catheter.  This  suture  is  of  catgut.  It  is  tied,  being  careful  to 
tuck  in  the  muscular  wall  of  the  bladder  around  the  catheter. 
This  produces  a  slight  spur  in  the  interior  of  the  bladder  which, 
after  the  catheter  is  removed,  favors  early  healing.  This 
suture  when  tied  insures  a  water-tight  joint  around  the  Pezzer 
catheter.  The  wound  is  then  reconstructed.  The  prevesical 
space  is  carefully  obliterated  by  the  catgut  suture.  The  fascia 
and  muscles  are  sutured  together  with  chromic  gut.  The 
skin  is  sutured  with  silk.  In  other  words,  all  of  the  planes 
of  tissue  are  brought  together  again  in  their  natural  position 
and  the  only  opening  is  the  line  through  which  the  catheter 
emerges.  It  is  possible  to  do  this  in  these  cases  because  the 
joint  around  the  Pezzer  catheter  is  water-tight  and  there 
will  be  no  leakage  for  over  a  week.  The  result  is  that  we  have 
a  primary  union  of  the  wound,  a  thoroughly  drained  bladder 
and  the  first  step  of  our  transvesical  prostatectomy  already 
completed. 

In  any  transvesical  prostatectomy  most  of  the  time  will 
be  consumed  in  making  the  suprapubic  incision  and  in  closing 


TRANSVESICAL  PROSTATECTOMY. 


33 


the  same.    By  this  method  this  step  of  the  operation  is  already- 
completed  before  the  prostatectomy  is  attempted. 

Whatever  shock  is  going  to  take  place  from  this  encroach- 
ment on  the  urinary  apparatus  in  cases  of  prostatic  hypertrophy 
will  become  evident  on  the  second  to  the  fifth  day  after  the 
suprapubic  cystostomy.    The  patient  is  in  the  best  possible  con- 

FiG.  32. 


'i^-^jm''f^''  -'W^P^'M 


Shows  the  way  in  which  the  Pezzer  catheter  is  fixed  into  the  bladder  wound, — the  stay 
suture  from  one  side  being  tied  on  the  opposite  side  of  the  tube  including  some  of  the  bladder 
wall,  and  the  one  from  the  other  side  tied  in  a  similar  manner.  These  will  hold  the  tube 
firmly  in  place.    A  purse-string  suture  is  used  for  the  same  purpose. 

dition  to  overcome  this  shock  because  there  has  been  no  loss  of 
blood,  no  general  ancesthetic,  and  no  special  pain,  all  of  which 
factors  tend  to  decrease  the  resisting  powers  of  the  organism. 
Almost  without  exception  in  cases  where  there  has  been  any 
great  retention,  there  is  a  marked  renal  reaction  which  occurs 
during  the  first  week,  as  previously  noted.  If  this,  then,  can  be 
eliminated  as  a  factor  of  the  prostatectomy  itself,  it  seems  to  us 
that  it  is  our  duty  to  do  this. 


34 


PAUL  MONROE  PILCHER. 


Two  Other  methods  have  been  devised  as  the  first  step  of 
the  transvesical  enucleation.  First,  the  use  of  a  permanent 
catheter.  This  question  has  already  been  discussed  (p.  528). 
The  objections  to  it  are :  In  the  first  place,  it  is  most  disagree- 
able to  many  patients ;  in  the  second  place,  it  almost  invariably 
excites  a  urethritis  which  frequently  causes  an  infection  of  the 
epididymis,  and  sometimes  affects  the  testicle.  These  are  un- 
fortunate complications.  In  the  third  place,  fatal  sepsis  has 
more  than  once  followed  the  using  of  a  permanent  catheter  in 
old  men  with  prostatic  disease. 

One  method  used  as  a  substitute  for  the  suprapubic  cystos- 
tomy  in  emergency  cases  is  the  puncture  with  a  trocar  above 
the  pubis.  This  is  not  without  danger  in  the  hands  of  some 
surgeons,  to  say  the  least,  and  it  does  not  in  any  way  shorten 
the  major  operation. 

My  chief  argument,  however,  is  that  by  doing  a  preliminary 
suprapubic  cystostomy  we  accomplish  everything  that  any  of 
the  other  methods  do;  we  are  able  to  do  it  under  a  local  anaes- 
thetic; we  have  exposed  the  suprapubic  tissues  to  infection 
and,  if  this  takes  place,  which  is  a  very  rare  occurrence  in  these 
cases,  it  may  be  overcome  and  will  subside  before  enucleation 
of  the  prostate  is  undertaken.  Again,  as  the  result  of  the 
preliminary  cystostomy,  the  cedema  and  swelling  around  the 
neck  of  the  bladder,  including  the  prostate,  greatly  diminish. 
I  have  seen  the  prostate  diminish  one-half  in  size  after  the 
suprapubic  cystostomy  alone.  This  is  of  advantage  in  the 
enucleation  and  the  healing  of  the  wound. 

V.    THE  TECHNIC  OF  TRANSVESICAL   PROSTATECTOMY. 

When  it  has  been  proven  to  the  surgeon's  satisfaction  that 
the  prostate  can  be  safely  removed,  judging  from  the  func- 
tional test  of  the  kidney  compared  with  the  original  functional 
test  and  taking  into  account  the  amount  of  urea  excreted  and 
the  evidences  of  acute  or  chronic  renal  disease,  as  well  as  the 
general  condition  of  the  patient,  as  previously  stated,  the 
operation  may  be  undertaken.  The  patient  is  prepared  as  for 
any  other  operation.    When  the  dressings  are  removed,  after 


Fig.  33. 


Pezzer  catheter  in  place  after  suprapubic  cystostomy.  Button  of  the  catheter  fits 
snugly  and  is  far  superior  to  the  ordinary  drainage  tube  inasmuch  as  it  does  not  permit  any 
rough  or  sharp  surface  to  irritate  the  prostate  or  the  bladder  wall.  This  idea  was  first  sug- 
gested to  me  by  Rovsing  and  is  the  method  which  he  follows. 

Fig.  34. 


The  surgical  problem.  The  picture  presented  illustrates  the  average  case  of  prostatic 
hypertrophy  with  a  special  development  of  the  median  lobe.  It  is  shown  to  emphasize  the 
bearing  of  the  surgical  pathology  upon  the  choice  of  method  of  operation. 


Fig.  35 


Illustrates  a  second  view  of  the  vesical  aspect  of  a  hypertrophied  prostate  showing  the 
irregularity  of  the  outgrowth  and  emphasizing  the  fact  that  the  prostatic  hypertrophy  is  a 
lesion  of  the  bladder  and  not  of  the  perineum. 


TRANSVESICAL  PROSTATECTOMY. 


35 


the  preliminary  cystostomy  using  the  Pezzer  catheter,  it  will 
be  found  that  the  wound  surrounding  the  catheter  has  healed 
by  primary  union.  TJie  silk  sutures  are  still  in  place.  These 
are  not  removed,  for  they  are  needed  to  hold  together  the  recent 
wound  while  the  finger  is  enucleating  the  prostate. 

First  step :  The  skin  is  prepared  with  iodine.    The  Pezzer 
catheter  is  removed  and  the  gloved  finger  introduced  into  the 

Fig.  36. 


Transvesical  prostatectomy.  Enucleation  of  the  prostate.  Usual  method.  Finger  is 
introduced  into  the  urethra  and  advanced  as  far  as  possible  before  breaking  through  the 
urethral  mucous  membrane.  Usually  the  line  of  cleavage  is  easily  found  from  the  urethra 
and  the  enucleation  is  accomplished  as  described  in  the  text. 

bladder  through  the  suprapubic  opening.  This  opening  easily 
dilates  sufficiently  to  allow  free  manipulation  of  the  finger. 
The  index  finger  of  the  other  hand  is  introduced  into  the  rectum 
and  the  prostate  is  lifted  up. 

Second  step:  Enucleation  of  the  prostate.  The  index  fin- 
ger of  the  enucleating  hand  is  introduced  into  the  prostatic 
urethra  and  advanced  as  far  as  possible,  reaching,  if  possible, 
the  furthest  point  of  the  prostatic  enlargement.    This  method, 


^6  PAUL  MONROE  PILCHER. 

as  shown  in  Fig.  36,  is  especially  useful  in  two  forms  of  pros- 
tatic enlargement,  that  which  is  due  to  an  irregular  enlargement 
of  both  lateral  lobes,  and  that  which  is  due  to  enlargement  of 
both  lateral  lobes  and  the  median  lobe,  even  though  the  median 
lobe  be  enlarged  out  of  all  proportion  to  the  other  two  lobes, 
as  in  Fig.  3.  With  the  finger  in  the  prostatic  urethra,  the  point 
of  least  resistance  in  the  mucous  membrane  of  the  urethra  is 
sought.    Usually  this  will  be  found  on  the  lateral  or  the  antero- 

FiG.  37. 


Drawing  illustrating  one  of  the  final  steps  in  enucleation  of  the  prostate.  The  lateral 
lobes  have  been  freed  and  the  mass  together  with  the  median  lobe  is  being  turned  over  and 
turned  into  the  bladder,  stripping  up  the  mucous  membrane  of  the  bladder  from  the  sur- 
face of  the  prostate. 

lateral  wall  of  the  urethra.  At  this  point  the  division  between 
the  prostate  and  the  urethra  is  usually  quite  easily  broken 
through.  In  all  of  my  recent  cases  I  have  been  able  to  gain  the 
line  of  cleavage  through  the  urethra  easily  with  the  gloved  fin- 
ger. The  finger  after  entering  the  line  of  cleavage  sweeps, 
first,  slowly  around  the  distal  portion  of  the  growt'  ,  and  then, 
up  over  the  anterior  surface  of  the  growth  separating  it  from 


Fig.  38. 


F'os  fe  fiof    Su  vfcL  c  e 


Median 
lobe 


Ptight    Lobe 


Paul   Pilche-r, 


Under  surface  of  prostatic  mass  showing  the  enormous  median  lobe  and  the  small  right  lobe. 
"A"  shows  the  torn  edges  of  the  mucous  membrane  stripped  up  from  posterior  surface. 


Fig.  40. 


Illustrating  the  method  used  by  Fenwick  to  control  hemorrhage  after  prostate  had  been 
removed.  Small  picture  in  upper  right  hand  corner  shows  condition  frequently  found  for 
a  small  blood-vessel  which  seemed  to  be  bleeding,  contained  in  the  torn  edges  of  the  bladder 
mucous  membrane.  Illustration  shows  the  speculum  in  place  with  the  neck  of  the  bladder 
exposed,  that  the  operator  may  directly  clamp  any  bleeding  vessel.  This  method  in  the 
hands  of  Fenwick  is  ideal. 


TRANSVESICAL  PROSTATECTOMY. 


Z7 


the  prevesical  tissue.  The  finger  is  then  passed  across  the 
urethra  to  the  other  side  with  a  sweeping  motion  of  the  finger 
and  the  opposite  lateral  lobe  is  freed.  Then  passing  the  finger 
up  over  the  entire  mass  an  attempt  is  made  to  turn  the  growth 
over  so  that  it  will  easily  turn  out  into  the  bladder  carrying 
with  it  the  median  lobe  (Fig.  37).  That  is  to  say,  the  finger  is 
passed  up  over  the  two  loosened  lateral  lobes  and  then  beneath 
the  same  between  the  enlarged  lobes  and  the  rectum,  and  then 

Fig.  39. 


\  f~  ~~i^  "01"' "  •  J 

^^^r^'  '-'^  /  ^V  t  '        '^-^      ^y^-.  .-^rl  "  ^-  ^'^  Paul  Ptlche'r. 


Drawing  illustrating  method  of  removing  a  massive  hypertrophy  of  the  prostate 
where  the  urethral  enucleation  is  impracticable.  This  is  applicable  in  the  large  bilateral 
hypertrophies.  The  illustration  shows  the  finger  raising  up  the  sphincter,  enucleating  the 
prostatic  mass  in  one  piece. 

the  finger  is  pulled  toward  the  bladder  so  that  the  growth  will 
turn  upon  itself,  as  is  shown  more  clearly  in  Fig.  37. 

As  the  growth  is  turned  out  into  the  bladder,  the  bladder 
mucous  membrane  will  be  stripped  up  from  the  posterior  side 
of  it,  as  may  be  seen  in  Fig.  38.  The  point  which  is  most 
difficult  to  free  is  the  attachment  at  the  junction  of  the  pros- 
tatic and  membranous  urethra,  which  is  seemingly  a  fibrous 
attachment,  or  may  be  the  attachment  to  the  atrophied  posterior 
lobe  which  lies  distal  to  the  ejaculatory  ducts  and  which  prob- 


38  PAUL  MONROE  PILCHER. 

ably  is  not  removed  in  the  majority  of  cases.  It  has  been  our 
experience  that  those  cases  in  which  the  prostate  does  not  shell 
out  easily  should  be  carefully  examined  for  evidences  of 
malignancy. 

The  other  type  of  prostate  which  is  occasionally  met  with 
is  the  enormous  prostate  which  seems  to  be  hypertrophied  in 
all  its  parts  with  the  exception  of  the  median  lobe.  Such  a 
prostate  is  seen  in  Fig.  12.  In  removing  this  prostate  it  may 
often  be  more  completely  and  more  easily  done  by  passing  the 
finger  between  the  sphincter  vesicae  and  the  growth  itself  and 
sweeping  the  finger  around  the  growth,  as  recommended  by 
Freyer.  It  will  quickly  fall  out  into  the  bladder.  This  method 
of  enucleation  is  illustrated  in  Fig.  39.  However,  in  the 
majority  of  cases  the  intra-urethral  enucleation  is  to  be  pre- 
ferred. It  is  quite  essential  for  the  welfare  of  the  patient  that 
all  of  the  prostate  as  far  as  possible  shall  be  removed.  Thus, 
Fig.  6  shows  a  prostate  with  a  very  large  median  lobe  and  two 
moderately  enlarged  lateral  lobes,  with  many  pieces  of  prostatic 
tissue  which  were  dug  out  from  the  capsule  after  the  main 
growth  had  been  removed.  The  operator  should  never  be  satis- 
fied with  removing  the  larger  adenomatous  mass  alone,  but 
an  attempt  should  be  made  to  bring  away  all  the  prostatic  tissue 
possible  unless  there  is  a  diffuse  carcinomatous  involvement. 
If  fragments  remain,  they  retard  the  healing  of  the  cavity  from 
which  the  prostate  has  been  removed  and  are  apt  to  necrose  and 
cause  a  delay  in  the  healing  of  the  bladder. 

Third  step:  Removing  the  prostatic  sections  and  the  Mood 
clots  from  the  Madder.  A  pair  of  forceps  is  passed  through 
the  suprapubic  wound  and  the  pieces  of  prostate  which  have 
been  turned  out  from  the  bladder  are  carefully  removed.  All 
of  the  blood  clots  in  the  bladder  should  be  washed  out  so  that 
no  pieces  of  foreign  material  are  left  behind. 

Control  of  the  Hemorrhage. — A  number  of  methods  have 
been  devised  for  controlling  the  hemorrhage. 

First,  the  Fenwick  method  by  clamp  and  ligature.  Fenwick 
has  devised  a  series  of  three  specula  of  different  sizes  which 
may  be  introduced  through  the  suprapubic  wound,  bringing 


TRANSVESICAL  PROSTATECTOMY.  39 

the  area  from  which  the  prostate  has  been  removed  directly  into 
view.  The  use  of  one  of  these  speculum  is  illustrated  in  Fig.  40. 
The  headlight  is  used  to  illuminate  the  cavity.  With  the  lacer- 
ated oozing  area  in  view  and  properly  illuminated,  the  area  is 
sponged  as  dry  as  possible  and  it  will  be  found,  as  a  rule,  that 
bleeding  does  not  come  so  much  from  the  cavity  from  zvhich 
the  prostate  has  been  removed,  but  usually  from  the  free  edges 
of  the  lacerated  tissue  which  covers  the  surface  of  the  prostate 
on  its  vesical  aspect.  This  was  very  beautifully  demonstrated 
to  the  writer  by  Mr.  Fenwick  himself.  In  one  case  he  was  able 
to  show  me  a  spurting  vessel  in  this  free  edge.  He  demon- 
strated further  that  the  area  from  which  the  prostate  has  been 
removed  flattens  out  very  quickly  and  does  not  remain  as  a 
cavity,  but  retracts  down  and,  as  a  rule,  does  not  allow  space  for 
the  accumulation  of  blood  clots.  Through  the  speculum  the 
bleeding  points  are  caught  with  specially  devised  hsemostats. 
In  this  way,  as  a  rule,  the  bleeding  can  be  entirely  controlled. 
In  most  cases  after  a  few  minutes  crushing  with  the  haemostats 
they  may  be  removed  and  no  further  bleeding  will  occur.  The 
haemostats  are  so  constructed  that  the  handles  may  be  remioved, 
if  necessary,  and  left  in  situ  for  24  hours. 

As  a  modification  of  this  method,  the  writer  would  suggest 
the  use  of  the  actual  cautery  through  the  speculum  to  control 
any  bleeding  point  which  might  come  into  view. 

Second,  control  by  suture.  A  number  of  prominent  opera- 
tors complete  their  prostatectomies  by  surrounding  the  area 
from  which  the  prostate  has  been  removed  by  a  continuous 
catgut  suture.  This  necessitates  a  large  suprapubic  wound 
and  consumes  considerable  time  and,  in  the  experience  of  the 
writer,  has  never  been  found  necessary. 

Third,  control  by  pressure.  With  one  finger  in  the  rectum 
and  a  finger  in  the  bladder  the  tissues  involved  in  the  prostatic 
wound  may  be  pressed  together  and  in  this  way  much  oozing 
will  be  prevented.  At  the  last  meeting  of  the  x^merican  Uro- 
logical  Society  in  Boston,  April,  191 3,  the  writer  presented 
a  method  of  controlling  hemorrhage,  using  gauze  packing.* 

*  Pilcher :  Transactions  of  the  American  Urol.  Soc,  1913,  vol.  vii,  p.  57. 


40 


PAUL  MONROE  PILCHER. 


This  consists  of  introducing  a  catheter  through  the  urethra 
which  serves  as  a  guide  and  centre  around  which  the  packing 
is  to  be  placed.  Then  a  narrow  strip  of  gauze  packing  is 
introduced  through  the  suprapubic  wound  and  the  torn  edges 
of  mucous  membrane  which  have  been  stripped  up  from  the 
prostate  are  pressed  down  into  the  shallow  prostatic  pouch  and 
held  in  place  by  gauze  packing,  as  is  shown  in  Figure  41.  This 
shows  the  prostatic  pouch  exaggerated  with  the  torn  flaps  of 
mucous  membrane  pushed  before  the  gauze  packing  and  in 
addition  the  Pezzer  catheter  used  to  hold  the  gauze  packing  in 
place.  This  Pezzer  catheter  may  be  introduced  by  first  passing 
a  silver  catheter  through  the  urethra  and  out  from  the  supra- 
pubic wound  and  then  attaching  the  small  end  of  the  Pezzer 
catheter  to  the  silver  catheter  and  drawing  it  out  through  the 
urethra.  With  the  expanded  end  of  the  catheter  on  the  vesical 
side  of  the  packing,  considerable  pressure  may  be  brought  to 
bear,  using  a  very  small  amount  of  gauze  packing  by  pulling 
on  the  penile  end  of  the  catheter.  Up  to  the  present  time  we 
have  always  used  the  simple  rubber  catheter  as  a  guide  and 
centre  around  which  to  pack  the  gauze.  The  end  of  the  gauze 
is  led  out  through  the  abdominal  wound  (Fig.  41).  Other 
methods  of  controlling  hemorrhage  by  direct  pressure  have 
been  devised,  but  none  of  them  are  superior  to  those  which 
have  been  mentioned. 

Control  of  Secondary  Hemorrhage  from  the  Bladder. — 
Hemorrhages  occurring  within  12  to  24  hours  after  the  prosta- 
tectomy are  best  controlled  by  packing  the  prostatic  pouch 
around  a  catheter  introduced  through  the  urethra.  In  one 
case  the  writer  passed  a  silk  suture  through  the  perineum, 
placed  a  gauze  packing  over  the  prostatic  pouch  and  fastened 
the  silk  suture  to  this  gauze  packing,  tying  the  same  on  the 
outside  of  the  perineum.  Secondary  hemorrhage  which  occurs 
a  week  or  so  after  the  operation  may  be  either  from  the  wound 
itself  which  calls  for  re-opening  the  wound  and  suture,  or  may 
be  from  the  vesical  neck  or  the  prostatic  pouch  itself.  Such  an 
occurrence  calls  for  re-opening  of  the  bladder,  exposure  of  the 
bleeding  point  and  securing  same  either  by  suture,  the  actual 


Fig.  41. 


Showing  method  of  controlHng  hemorrhage  by  the  use  of  packing.  The  Pezzer  catheter 
is  introduced  by  first  passing  a  silver  catheter  through  the  urethra  and  out  through  the  supra- 
pubic wound  attaching  the  Pezzer  catheter  to  the  silver  catheter  and  withdrawing  same 
through  the  urethra.  When  the  Pezzer  catheter  is  in  place,  the  packing  is  inserted,  consisting 
of  narrow  gauze,  introducing  it  in  such  a  way  that  the  torn  mucous  membrane  flaps  of  the 
bladder  are  pushed  ahead  of  the  packing  and  when  the^  packing  is  in  place  the  Pezzer  catheter 
is  pulled  down,  keeping  the  packing  in  place  and  exerting  pressure  against  the  bleeding 
surface  at  the  same  time.  In  order  to  hold  the  Pezzer  catheter  firmly  in  place,  it  should 
be  attached  to  the  leg  by  adhesive  plaster.  The  gauze  is  removed  after  24  hours  and  the 
catheter  at  will. 


Fig.  42. 


Appearance  of  suprapubic  scar  two  weeks  after  the  operation.    It  is  meant  especially  to  show 
the  clean  appearance  of  the  wound  which  is  entirely  free  of  incrustations  or  sloughs. 


TRANSVESICAL  PROSTATECTOMY. 


41 


cautery  or  the  high-frequency  spark  generated  from  the 
D'Arsonval  current.  In  one  case  of  my  own,  it  was  necessary 
after  the  second  week  to  re-open  the  bladder  widely  and  cauter- 
ize the  entire  area  of  the  vesical  neck  before  the  hemorrhage 
could  be  stopped. 

Drainage  of  the  Bladder  After  Transvesical  Prostatectomy. 
— To  the  mind  of  the  writer,  it  is  very  essential  to  drain  the 
bladder  suprapubically  after  every  case  of  prostatectomy.  We 
consider  it  dangerous  and  unnecessary  to  run  the  risk  of  closing 
the  bladder  after  transvesical  prostatectomy.  This  has  been 
emphasized  in  our  own  experience  in  two  cases  in  which  we 
closed  the  bladder  and  were  compelled  to  re-open  and  drain 
the  bladder  on  account  of  severe  hemorrhage  within  the  bladder 
which  clogged  the  urethral  catheter.  Our  routine  is,  as  soon 
as  the  prostate  is  removed  and  the  hemorrhage  checked,  to 
introduce  a  large  rubber  drainage  tube,  one  inch  in  diameter, 
just  within  the  wall  of  the  bladder,  and  after  securing  it  in 
place  to  apply  copious  gauze  dressings  over  the  same.  If  the 
packing  of  the  prostatic  pouch  is  necessary,  a  small  gauze  pack- 
ing is  brought  out  through  the  large  drainage  tube.  It  should 
be  emphasized  at  this  point  that  none  of  the  silk  skin  sutures 
introduced  at  the  primary  operation  have  been  removed,  and 
that  after  the  enucleation  of  the  prostate  no  suturing  of  the 
wound  is  necessary.  The  cystostomy  wound  made  at  the  first 
operation  is  capable  of  very  great  distention  without  tearing 
it  open  if  the  original  sutures  have  not  been  removed. 

After-treatment. — As  soon  as  the  patient  has  been  returned 
to  his  bed  a  proctoclysis  of  tap  water  is  begun  and  the  abdominal 
dressings  changed  as  frequently  as  necessary.  After  24  hours 
the  bladder  is  irrigated  through  the  suprapubic  tube  which  is 
still  in  place.  If  packing  is  in  place  it  is  removed,  together 
with  the  large  suprapubic  drainage  tube.  The  Pezzer  catheter 
replaces  the  suprapubic  drainage  tube.  It  will  be  found  that 
in  six  to  eight  hours  the  bladder  wall  will  contract  around  the 
Pezzer  catheter  and  very  little  urine  will  leak  out  beside  it. 
The  Pezzer  catheter  is  left  in  place  for  three  or  four  days 
until  the  wound  surfaces  have  healed  over.    This  tends  to  pre- 


42 


PAUL  MONROE  PILCHER. 


vent  the  formation  of  sloughs  and  phosphatic  concretions  on 
the  wound  surfaces  (Fig.  42).  Also,  the  use  of  drugs  to  pre- 
vent alkalinity  of  the  urine  will  tend  to  give  a  better  wound. 
On  the  fourth  or  fifth  day  the  Pezzer  catheter  is  removed 
and  is  replaced  by  a  collecting  device  of  an  English  maker, 
which  is  shown  in  Fig.  43.  The  wound  is  strapped  with  a 
piece  of  inch-wide  adhesive  tape  and  what  urine  escapes  is 

Fig.  43. 


collected  in  the  celluloid  cup  and  drains  from  the  cup  into  a 
bottle  through  a  rubber  tube.  This  ingenious  device  is  held 
in  place  by  rubber  straps  which  keep  it  from  slipping.  It  is  a 
very  convenient  and  comfortable  adjunct  to  the  convalescence. 
If  the  suprapubic  cup  is  not  available,  the  use  merely  of  masses 
of  absorbent  gauze  over  the  fistula  will  answer  any  need  until 
the  fistula  closes  and  normal  urethral  urination  is  re-established. 
The  period  of  healing  of  the  suprapubic  wound  has  in  our 
experience  taken  from  one  week  to  four  weeks,  the  average  be- 


TRANSVESICAL  PROSTATECTOMY. 


43 


ing  about  i6  days.  In  none  of  our  cases  has  there  been  any 
permanent  suprapubic  fistula.  The  nearest  approach  to  it  was 
in  the  case  of  recurrent  secondary  hemorrhage  in  which  the 
bladder  was  twice  widely  opened  in  order  to  control  the  hemor- 
rhage.   In  one  case  the  suprapubic  wound  closed  in  four  days. 

Control  of  the  Urine. — About  the  eighth  to  tenth  day,  as  a 
rule,  small  amounts  of  urine  will  pass  per  uretliram,  the  amount 
increasing  as  the  suprapubic  wound  contracts.  It  is  worthy 
of  note  that  in  none  of  our  recent  cases  has  dribbling  been 
noticed,  and  that  within  two  or  three  Aveeks  after  the  operation 
the  patients  have  fairly  good  control,  and  in  all  the  cases  oper- 
ated upon  by  us  after  this  method  the  result  has  been  full 
control  of  the  urine  with  complete  emptying  of  the  bladder. 

Potency  of  the  Male. — This  operation  does  not  seem  to 
interfere  with  the  functions  of  the  ejaculatory  ducts,  in  fact, 
in  a  number  of  instances  the  potency  has  increased  as  a  result 
of  the  operation. 

CONCLUSIONS. 

Studies  of  the  living  pathology  of  chronic  prostatism  lead 
us  to  the  conclusion  that  obstructive  prostatic  hypertrophy 
usually  involves  the  two  lateral  lobes  and  the  median  lobe,  and 
that  inasmuch  as  the  obstruction  is  at  the  neck, of  the  bladder 
and  the  obstructing  body  projects  into  the  bladder,  the  natural 
avenue  of  approach  is  the  transvesical  route. 

Second,  as  a  result  of  relieving  the  distention  of  the  blad- 
der, three  phases  of  kidney  secretion  are  demonstrable;  the 
second  phase,  lasting  from  a  few  days  to  a  number  of  weeks, 
constitutes  a  period  of  danger  during  which  no  surgical  attack 
should  be  undertaken. 

Third,  the  technic  advocated  in  the  present  paper  includes 
a  two-step  transvesical  operation  in  every  instance  for  the 
relief  of  benign  hypertrophy  of  the  prostate.  Preliminary 
cystostomy  is  preferred  for  the  reason  that,  following  the 
suprapubic  cystostomy  the  patient  is  out  of  bed  in  24  hours; 
the  urinary  output  from  the  bladder  is  completely  controlled; 
there  is  no  unpleasantness  or  traumatism  due  to  the  passage  of 


A  A  PAUL  MONROE  PILCHER. 

the  catheter  through  the  urethra,  and  the  operation  of  trans- 
vesical prostatectomy  is  already  half  completed. 

Fourth,  since  applying  these  principles  we  are  able  to  report 
to  date  28  successive  successful  cases,  every  case  resulting  in 
the  control  of  urine  by  the  patient  and  his  ability  to  empty  the 
bladder  without  using  a  catheter.  In  some  cases  of  enormous 
distention  of  the  bladder,  it  is  necessary  to  catheterize  for  a 
certain  length  of  time  before  employing  suprapubic  cystostomy 
on  account  of  the  extreme  back  pressure  on  the  kidneys,  the 
sudden  decompression  of  which  might  result  fatally. 

Fifth,  these  same  rules  do  not  apply  in  cases  where  carci- 
noma of  the  prostate  has  been  diagnosed,  or  even  where  its 
presence  is  fairly  well  suspected.  A  later  communication 
will  deal  with  this  part  of  the  subject. 

REFERENCES. 

Pilcher :     Obstructive  Hypertrophy  of  the   Prostate  Body.     Annals  of 

Surgery,  vol.  xh,  p.  481,  April,  1905. 
Tandler  and  Zuckerkandl :  Folia  Urologica  Internationales  Archiv  f iir  die 

Krankheiten  der  Harnorgane,  March,  191 1. 
Lowsley:  Jour.  A.  M.  A.,  January  11,  1913,  page  no. 
Wilson  and  McGrath :  Surgical  Pathology  of  the  Prostate.    Surg.  Gyn.  and 

Obs.,  December,  191 1,  p.  647-681. 
Squier,  J.  Bentley:  Vital  Statistics  of  Prostatectomy.   Surg.,  Gyn.  and  Obs., 

vol.  17,  No.  4,  page  433. 
Albarran :  Maladies  de  la  Prostate,  1902,  page  546. 

Watson,  F.  S. :  Operative  Treatment  of  the  Hypertrophied  Prostate,  1888. 
Wade,   H. :   Prostatism.     The   Surgical  Anatomy  and   Pathology  of  the 

Operative  Treatment.    Annals  of  Surgb:ry,  March,  1914,  vol.  lix.  No.  3, 

page  321. 


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